Predicting suicide attempts and suicide deaths among adolescents following outpatient visits

BACKGROUND

Few studies report on machine learning models for suicide risk prediction in adolescents and their utility in identifying those in need of further evaluation. This study examined whether a model trained and validated using data from all age groups works as well for adolescents or whether it could be improved.

METHODS

We used healthcare data for 1.4 million specialty mental health and primary care outpatient visits among 256,823 adolescents across 7 health systems. The prediction target was 90-day risk of suicide attempt following a visit. We used logistic regression with least absolute shrinkage and selection operator (LASSO) and generalized estimating equations (GEE) to predict risk. We compared performance of three models: an existing model, a recalibrated version of that model, and a newly-learned model. Models were compared using area under the receiver operating curve (AUC), sensitivity, specificity, positive predictive value and negative predictive value.

RESULTS

The AUC produced by the existing model for specialty mental health visits estimated in adolescents alone (0.796; [0.789, 0.802]) was not significantly different than the AUC of the recalibrated existing model (0.794; [0.787, 0.80]) or the newly-learned model (0.795; [0.789, 0.801]). Predicted risk following primary care visits was also similar: existing (0.855; [0.844, 0.866]), recalibrated (0.85 [0.839, 0.862]), newly-learned (0.842, [0.829, 0.854]).

LIMITATIONS

The models did not incorporate non-healthcare risk factors. The models relied on ICD9-CM codes for diagnoses and outcome measurement.

CONCLUSIONS

Prediction models already in operational use by health systems can be reliably employed for identifying adolescents in need of further evaluation.

Safer use of antipsychotics in youth (SUAY) pragmatic trial protocol

BACKGROUND

Programs such as the Pediatric Access Line in Washington state have shown decreases in antipsychotic medication use by youth with non-psychotic disorders. Program outcomes have been studied with observational designs. This manuscript describes the protocol for Targeted and Safer Use of Antipsychotics in Youth (SUAY), a randomized controlled trial of psychiatrist review of prescriptions and facilitated access to psychosocial care. The aim of the intervention is to reduce the number of person-days of antipsychotic use among participants.

METHODS

Recruitment occurs at 4 health systems. Targeted enrollment is 800 youth aged 3-17 years. Clinicians are block randomized to intervention versus usual care prior to the study. Youth are nested within the arm of the prescribing clinician. Clinicians in the intervention group receive an EHR-based best practice alert with options to expedite access to psychosocial care and all medication orders are reviewed by a child and adolescent psychiatrist with feedback provided to the prescriber. The primary outcome is person-days of antipsychotic medication use in the 6 months following the initial order. All randomized individuals contribute data regardless of their level of participation (including declining all services).

DISCUSSION

The trial has been approved by the institutional review boards at each of the 4 sites. The intervention has 4 novel design features including automated recruitment using a best practice alert, psychiatrist medication order review and consultation, telephone navigation to psychosocial care, and telemental health visits. Recruitment began in March of 2018 and will be completed in June 2020. Follow-up will be completed December 31, 2020.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03448575.

Prevention of Depression in At-Risk Adolescents: Moderators of Long-term Response

In a randomized controlled trial, we found that a cognitive behavioral program (CBP) was significantly more effective than usual care (UC) in preventing the onset of depressive episodes, although not everyone benefitted from the CBP intervention. The present paper explored this heterogeneity of response. Participants were 316 adolescents (M age = 14.8, SD = 1.4) at risk for depression due to having had a prior depressive episode or having current subsyndromal depressive symptoms and having a parent with a history of depression. Using a recursive partitioning approach to baseline characteristics, we (Weersing et al. 2016) previously had identified distinct risk clusters within conditions that predicted depressive episodes through the end of the continuation phase (month 9). The present study used the same risk clusters that had been derived in the CBP group through month 9 to reclassify the UC group and then to examine group differences in depression through month 33. We found that in this overall very high-risk sample, the CBP program was superior to UC among youth in the low-risk cluster (n = 33), characterized by higher functioning, lower anxiety, and parents not depressed at baseline, but not in the middle (n = 95) and high-risk (n = 25) clusters. Across conditions, significantly more depression-free days were found for youth in the low-risk cluster (M = 951.9, SD = 138.8) as compared to youth in the high-risk cluster (M = 800.5, SD = 226.7). Identification of moderators, based on purely prognostic indices, allows for more efficient use of resources and suggests possible prevention targets so as to increase the power of the intervention.

Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings

In this report, we conducted a secondary analysis of the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study to explore the impact of specific cognitive-behavioral therapy (CBT) treatment components on outcome. In TORDIA, 334 youths (ages 12 to 18 years) with major depressive disorder who had failed to respond to an adequate course of selective serotonin reuptake inhibitor (SSRI) medication were randomized to a medication switch (either to an alternative SSRI or venlafaxine) with or without 12 weeks of adjunctive CBT. Participants who had more than 9 CBT sessions were 2.5 times more likely to have adequate treatment response than those who had 9 or fewer sessions. CBT participants who received problem-solving and social skills treatment components, controlling for number of sessions and other confounding variables, were 2.3 and 2.6 times, respectively, more likely to have a positive response. These preliminary findings underscore the importance of receiving an adequate number of sessions to attain an adequate clinical response. Finally, social skills and problem solving may be active elements in CBT for adolescent depression and should be considered in treatment by those working with seriously depressed youths.

Hyperactivation of capacitated human sperm correlates with the zona pellucida-induced acrosome reaction of zona pellucida-bound sperm

BACKGROUND

The aim of this study was to determine the relationship between human sperm hyperactivation (HA), sperm-zona pellucida (ZP) binding and the ZP-induced acrosome reaction (AR) of ZP-bound sperm in vitro.

METHODS

Sperm samples from 129 infertile men were studied. Motile sperm (2 x 10(6)) selected by Pure sperm were incubated with four oocytes in 1 ml human tubal fluid supplemented with 10% human serum. After 2-h incubation, the number of sperm bound to the ZP and the AR of ZP-bound sperm were examined. Velocities and HA of sperm in insemination medium were assessed by Hamilton-Thorn Sperm Analyzer.

RESULTS

The HA was highly correlated with the ZP-induced AR in all the subjects (rho = 0.626, P < 0.001). In the 69 men with < or = 100 sperm bound/ZP, allowing accurate counts, HA was not significantly correlated with sperm-ZP binding. Men with <7% HA sperm were more likely to have very low ZP-induced AR. Only normal sperm morphology was significantly correlated with sperm-ZP binding (rho = 0.346 and 0.446 in semen and insemination medium, respectively, both P < 0.001). Sperm motility and velocities were significantly correlated with sperm morphology but not with either sperm-ZP binding or the ZP-induced AR.

CONCLUSIONS

The correlation of HA with the ZP-induced AR of ZP-bound sperm suggests a mechanistic link between HA and the physiological AR in humans. Assessment of HA of capacitated sperm in vitro may be a useful clinical test for male infertility associated with defective ZP-induced AR that does not require the use of human oocytes.

Antisperm antibodies and conception

Sperm have been known to be antigenic for more than a century. There is a strong body of evidence that in humans and in other species at least some antibodies that bind to sperm antigens can cause infertility. Therefore, these antibodies are of interest today for two practical reasons. Firstly, the association of the antibodies with infertility means that they must be detected and then the couples treated appropriately. Secondly, because these antibodies can induce infertility they have the potential to be developed for contraceptive purposes in humans and also for the control of feral animal populations.

Tyrosine phosphorylation on capacitated human sperm tail detected by immunofluorescence correlates strongly with sperm-zona pellucida (ZP) binding but not with the ZP-induced acrosome reaction

BACKGROUND

Protein tyrosine phosphorylation (TP) of human sperm is related to sperm capacitation and zona pellucida (ZP) binding. The aim of this study was to determine whether the TP of capacitated sperm is a useful marker for the ability of sperm to bind to the ZP and undergo the ZP-induced acrosome reaction (AR).

METHODS

Semen samples were obtained from 115 subfertile men with sperm count > or =20 x 10(6)/ml, motility > or =25% and variable morphology. Motile sperm (2 x 10(6)/ml) selected by swim-up were incubated with four oocytes for 2 h, and the number of sperm bound to the ZP and the ZP-induced AR was examined. TP of sperm tail was assessed by immunofluorescence (IF) with anti-phosphotyrosine monoclonal antibody. The time course and effects of dibutyryl cyclic adenosine monophosphate (dbcAMP) and phorbol myristate acetate (PMA) on TP were also studied.

RESULTS

TP was stimulated more by dbcAMP (P < 0.001) and less by PMA (P < 0.05). TP increased significantly with time of incubation of sperm. TP was not detectable on the surface of unfixed live sperm by either Dynabeads or IF. Sperm TP at 2, 4 and 20 h incubation was all significantly correlated with sperm-ZP binding but not with the ZP-induced AR.

CONCLUSION

Sperm TP detected by IF correlates strongly with sperm-ZP binding capacity but not with the ZP-induced AR. This simple IF assay of TP may be a clinically useful test of sperm function that is predictive of normal sperm ZP-binding capacity.

Hyper-osmotic condition enhances protein tyrosine phosphorylation and zona pellucida binding capacity of human sperm

BACKGROUND

The aim of this study was to determine the effect of culture medium osmolality, in the range known to occur in the male and female reproductive tracts, on human sperm tyrosine phosphorylation and sperm-zona pellucida (ZP) interaction in vitro.

METHODS

Motile sperm (2x10(6)), selected by swim-up from semen of normozoospermic men with normal sperm-ZP binding, were incubated with or without four oocytes in 1 ml human tubal fluid (HTF) medium with different osmolalities (150, 200, 280, 350, 400 mOsm/kg) adjusted by variation of the NaCl concentration. After 2 h incubation, the number of sperm bound to the four ZP was examined, sperm motility and velocities were assessed by Hamilton-Thorn Motility Analyzer (IVOS 10) and sperm tyrosine phosphorylation was assessed by both western immunoblotting and immunofluorescence with an anti-phosphotyrosine monoclonal antibody (PY20). The effect of hyper-osmolality (400 mOsm/kg) on the ZP-induced acrosome reaction (AR) was also determined.

RESULTS

Incubation of human sperm in hyper-osmotic medium significantly increased tyrosine phosphorylation and the number of sperm bound to the ZP. In contrast, hypo-osmotic medium significantly decreased both tyrosine phosphorylation and sperm-ZP binding. Medium with high osmolality (400 mOsm/kg) significantly reduced the ZP-induced AR. Both hypo- and hyper-osmotic media significantly decreased average sperm percentage progressive motility and velocities.

CONCLUSION

Incubation of human sperm in hyper-osmotic media was associated with significantly increased tyrosine phosphorylation and ZP-binding ability but severely reduced the ZP-induced AR.

Exposure of actin on the surface of the human sperm head during in vitro culture relates to sperm morphology, capacitation and zona binding

BACKGROUND

The aim of this study was to determine the relationship between the proportion of motile sperm with actin exposed on the surface of the head and sperm function.

METHODS

Semen samples were obtained from normozoospermic men and sperm function tests were performed. Motile sperm selected by swim-up were incubated with actin monoclonal antibody (A-mAb, 1:100) for 2 h, then anti-mouse IgG Dynabeads were used to detect sperm-bound A-mAb. Sperm capacitation was increased by phorbol myristate acetate (PMA) and decreased by bicarbonate-free medium.

RESULTS

The proportion of sperm with exposed actin increased with time for up to 2 h incubation. Bicarbonate-free medium significantly decreased the proportion of sperm with exposed actin. PMA significantly enhanced this phenomenon. Sperm bound to zona pellucida (ZP) had a significantly higher proportion with exposed actin than did sperm remaining in medium. Of the 79 samples studied, an average of 9.4% (range 1-27%) of motile sperm had exposed actin after 2 h incubation and this was significantly correlated with sperm normal morphology and ZP binding.

CONCLUSION

Exposure of actin on the surface of the sperm head during in vitro culture may be related to membrane modification during sperm capacitation and hence may be a useful marker for this subpopulation of sperm.

Automated semen analysis: 'zona pellucida preferred' sperm morphometry and straight-line velocity are related to pregnancy rate in subfertile couples

BACKGROUND

Standard semen analysis has low objectivity and reproducibility and is not closely related to fertility. We assess the prognostic value of automated measurements of sperm motility and morphology.

METHODS

During 1997-1999, 1191 infertile couples with no known absolute barrier to conception were assessed by conventional semen analysis, and automated measurements of average straight-line velocity (VSL) and the percentage of sperm with characteristics that conform to those of sperm which bind to the zona pellucida of the human oocyte (%Z). During follow-up to 2001, there were 336 natural pregnancies.

RESULTS

Only %Z, VSL and female age were independently significantly related to pregnancy rate by Cox regression analysis. Pregnancy rate was higher with above average %Z and VSL, indicating a continuous rather than a threshold relationship. The likelihood of pregnancy within 12 cycles can be evaluated for specific values of %Z, VSL and female age using the Cox regression model.

CONCLUSIONS

The automated semen measures of sperm morphometry (%Z) and velocity (VSL) are related to pregnancy rates in subfertile couples and should assist clinicians in counselling subfertile patients about their prognosis for a natural pregnancy. Objective automated methods should replace the traditional manual assessments of semen quality.

Improved sperm cryopreservation using cold cryoprotectant

It has generally been assumed that very rapid cooling above freezing point would be deleterious to human sperm because it would result in cold shock. Consequently, most routine cryopreservation protocols involve the use of warm (20–30°C) cryoprotectant and slow cooling above the freezing point in order to minimise the risk of cold shock. In order to test this assumption, we added an equal volume of cold (4°C) cryoprotectant in a single aliquot to warm (20, 30 or 37°C) semen to induce rapid cooling. The results of this procedure were compared with those obtained using warm cryoprotectant or with the routine cryopreservation protocol used in this laboratory. The use of cold cryoprotectant resulted in a significant (P = 0.016) improvement (mean 63%, range 42%–79%) in post-thaw motility recovery compared with a standard procedure(mean 47%, range 35%–67%) and a significant (P = 0.016) improvement in post-thaw sperm velocity. A cold glycerol/egg yolk/citrate (GEYC) mixture also gave significantly higher motility recovery than GEYC equilibrated to either room temperature (20°C) or body temperature (37°C). Sperm frozen using the cold cryoprotectant protocol were as efficient at binding to and penetrating the human zona pellucida as sperm frozen with a standard protocol.The modified cryopreservation procedure may lead to improved pregnancy rates in donor insemination and in vitro fertilisation. Further investigation is required to determine how the cold cryoprotectant improves the cryopreservation outcome.

An anti-actin monoclonal antibody inhibits the zona pellucida-induced acrosome reaction and hyperactivated motility of human sperm

We report an inhibitory effect of an anti-actin monoclonal antibody (mAb) on the human zona pellucida (ZP)-induced acrosome reaction (AR). Motile sperm were incubated with native human ZP for 2 h in medium containing either the anti-actin mAb, an irrelevant control mAb or cytochalasins B or D (40 micromol/l). Sperm bound to the ZP were recovered and the AR was determined by fluorescein-labelled Pisum Sativum agglutinin. Anti-mouse immunoglobulin G (mIgG) Dynabeads, immunofluorescence and immunogold were used to detect the location of the anti-actin mAb in sperm. The anti-actin mAb significantly inhibited the ZP-induced AR (equivalent to cytochalasins), the ionophore A23187-induced AR and hyperactivation of sperm in medium. After incubation with anti-actin mAb, anti-mIgG beads bound to the head of >50% of sperm recovered after binding to the ZP and 10% of sperm remaining in the medium. The proportion of sperm that bound anti-mIgG beads after recovery from binding to the ZP in the presence of the anti-actin mAb was significantly correlated with the ZP-induced AR in the absence of the antibody. Immunofluorescence and immunogold demonstrated entry of the anti-actin mAb into sperm. This study suggests that the sperm plasma membrane becomes permeable to the anti-actin mAb during capacitation and initiation of the AR.

A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents

BACKGROUND

Adolescent offspring of depressed parents are at high risk for development of depression. Cognitive restructuring therapy holds promise for preventing progression to depressive episodes.

METHODS

A randomized, controlled trial was conducted to prevent depressive episodes in at-risk offspring (aged 13-18 years) of adults treated for depression in a health maintenance organization (HMO). Potential adult cases were found by reviewing the HMO pharmacy records for dispensation of antidepressant medication and the mental health appointment system. Medical charts were reviewed for a depression diagnosis. Recruitment letters signed by treating physicians were mailed to adults. Eligible offspring had subdiagnostic depressive symptoms insufficient to meet full DSM-III-R criteria for affective disorder and/or a past mood disorder. These youth were randomized to usual HMO care (n = 49) or usual care plus a 15-session group cognitive therapy prevention program (n = 45).

RESULTS

We detected significant treatment-by-time (program) effects for the Center for Epidemiological Studies Depression Scale (P=.005) and the Global Assessment of Functioning scores (P =.04). Survival analysis of incident major depressive episodes during a median 15-month follow-up found a significant advantage (P =.003) for the experimental condition (9.3% cumulative major depression incidence) compared with the usual-care control condition (28.8%).

CONCLUSION

A brief, group cognitive therapy prevention program can reduce the risk for depression in the adolescent offspring of parents with a history of depression.

Screening for anxiety and depression in early adolescence

OBJECTIVE

To examine the level of diagnostic and discriminative accuracy of three dimensional rating scales for detecting anxiety and depressive disorders in a school-based survey of 9th grade youths.

METHOD

Classroom screening instruments, the Center for Epidemiologic Studies-Depression Scale (CES-D), the Revised Children's Manifest Anxiety Scale (RCMAS), and the Multidimensional Anxiety Scale for Children (MASC) were administered to 632 youths from three sites in 1998. On the basis of rating scale results, samples of high-scoring and non-high-scoring youths were invited to participate in a diagnostic interview conducted within 2 months of the screening sessions.

RESULTS

MASC scores were most strongly associated with individual anxiety disorders, particularly among females, whereas the CES-D composite score was associated with a diagnosis of major depression, after controlling for comorbid disorders. The RCMAS was least successful in discriminating anxiety and depression. When receiver operator characteristic curves were examined, diagnostic accuracy was moderate.

CONCLUSIONS

The ability of the MASC and CES-D to discriminate within and between categorically defined diagnostic groups has important implications for the accurate identification of youths in need of services.

Effectiveness of antidepressant pharmacotherapy: the impact of medication compliance and patient education

This study was designed to investigate the impact of a time-phased patient education program (RHYTHMS) on medication compliance and treatment outcomes of primary care patients diagnosed with major depression and started on antidepressant pharmacotherapy. Two hundred forty-six depressed patients, diagnosed and treated at one of three outpatient clinics affiliated with the Kaiser-Permanente Northwest Region (KPNW) healthcare system, were randomly assigned to either receive or not receive (usual care) the educational materials by mail. Depression severity and functional impairment affecting patients' quality of life were assessed at baseline and 4, 12, and 30 weeks later. Self-reported impressions of improvement and patient satisfaction with treatment were also assessed at follow-up. Clinical assessment data were obtained using an interactive voice response (IVR) system. Study subjects were compensated $5, $10, $15, and $25 for completing each assessment (Baseline to Week 30, respectively). Upon study completion, prescription fill data of the subjects were extracted from the KPNW Pharmacy System for analysis of medication compliance. Most of the study subjects (63.5%) responded to the pharmacotherapy treatment by study end-point. Few statistically significant differences in either treatment outcomes or duration of medication compliance were found between the treatment groups, and significant differences found were of fairly small magnitude. Patients not receiving the educational materials initially exhibited a more positive response to treatment (Week 4), but this difference did not persist at later follow-ups and was associated with significantly higher relapse rates. A strong time-dose relationship was evident between the duration of the initial treatment episode and treatment outcomes at follow-up, but randomized treatment assignment did not influence the duration of initial medication compliance. Educational programs designed to encourage depressed patients to obtain adequate pharmacotherapy likely provide medical benefits. Such benefits appear to be relatively subtle and methodological differences between studies contribute to inconsistent conclusions concerning observed benefits. The intent of providing time-phased educational materials to patients is to maximize the relevance of such information by synchronizing it with typical recovery processes and issues. This study suggests that additional efforts at engaging patients earlier after the initiation of treatment might be of most benefit.

Impact of comorbidity on a cognitive-behavioral group treatment for adolescent depression

OBJECTIVE

Examine hypotheses concerning the negative impact of lifetime psychiatric comorbidity on participation in, and benefit from, a cognitive-behavioral group treatment for depression in adolescents (e.g., greater severity at intake, less recovery and more recurrence, less participation in treatment).

METHOD

Across two previous studies conducted between 1986 and 1993, 151 depressed adolescents (aged 14-18) were randomly assigned to one of three treatment conditions (two active treatments and a waitlist control) and followed for 24 months posttreatment. Forty percent of participants had one or more lifetime comorbid diagnoses at intake.

RESULTS

Comorbid anxiety disorders were associated with higher depression measure scores at intake and greater decrease in depression scores by posttreatment. Overall lifetime comorbidity was unrelated to diagnostic recovery, but lifetime substance abuse/dependence was associated with slower time to recovery. Participants with attention-deficit and disruptive behavior disorders were more likely to experience depression recurrence posttreatment. Associations between comorbidity and participation or therapy process measures were nonsignificant.

CONCLUSIONS

Although some outcomes were worse for some comorbid diagnoses, the reassuring overall conclusion is that the presence of psychiatric comorbidity is generally not a contraindication for the use of structured group cognitive-behavioral interventions for depressed adolescents.

Efficacy of paroxetine in the treatment of adolescent major depression: a randomized, controlled trial

OBJECTIVE

To compare paroxetine with placebo and imipramine with placebo for the treatment of adolescent depression.

METHOD

After a 7- to 14-day screening period, 275 adolescents with major depression began 8 weeks of double-blind paroxetine (20-40 mg), imipramine (gradual upward titration to 200-300 mg), or placebo. The two primary outcome measures were endpoint response (Hamilton Rating Scale for Depression [HAM-D] score < or = 8 or > or = 50% reduction in baseline HAM-D) and change from baseline HAM-D score. Other depression-related variables were (1) HAM-D depressed mood item; (2) depression item of the Schedule for Affective Disorders and Schizophrenia for Adolescents-Lifetime version (K-SADS-L); (3) Clinical Global Impression (CGI) improvement scores of 1 or 2; (4) nine-item depression subscale of K-SADS-L; and (5) mean CGI improvement scores.

RESULTS

Paroxetine demonstrated significantly greater improvement compared with placebo in HAM-D total score < or = 8, HAM-D depressed mood item, K-SADS-L depressed mood item, and CGI score of 1 or 2. The response to imipramine was not significantly different from placebo for any measure. Neither paroxetine nor imipramine differed significantly from placebo on parent- or self-rating measures. Withdrawal rates for adverse effects were 9.7% and 6.9% for paroxetine and placebo, respectively. Of 31.5% of subjects stopping imipramine therapy because of adverse effects, nearly one third did so because of adverse cardiovascular effects.

CONCLUSIONS

Paroxetine is generally well tolerated and effective for major depression in adolescents.

Frequency of disordered zona pellucida (ZP)-induced acrosome reaction in infertile men with normal semen analysis and normal spermatozoa-ZP binding

Results of zona pellucida (ZP)-induced acrosome reaction (AR) are reported for 186 normospermic men with unexplained infertility and compared with 34 normal fertile men and 54 patients with disordered ZP-induced AR (DZPIAR) diagnosed after failure of standard IVF. For each ZP-induced AR test, four oocytes that failed to fertilize in IVF were incubated for 2 h with 2x10(6)/ml motile spermatozoa. Spermatozoa tightly bound to the ZP were recovered by aspirating the oocytes with a pipette and the AR assessed using pisum sativum agglutinin labelled with fluorescein. The standard deviation of the difference was 5.2% for repeated tests for ZP-induced AR on different ejaculates from 54 men. The ranges for the ZP-induced AR were 3-98% for normospermic infertile men, 24-95% for fertile men and 0-16% for DZPIAR patients. In the normospermic group, there was a significant correlation between ZP-induced AR and sperm concentration (Spearman r = 0.238, P < 0.001). Using ZP-induced AR < or =16% as the threshold for diagnosis of DZPIAR, the frequency of this condition in normospermic infertile men would be 25%. Thus DZPIAR is common with normospermic idiopathic infertility and this condition should be diagnosed before assisted reproductive technology since it requires intracytoplasmic sperm injection.

Treated prevalence, incidence, and pharmacotherapy of child and adolescent mood disorders in an HMO

This study examined the "treated" prevalence, incidence, and pharmacotherapy of child and adolescent mood disorders in a managed care setting. General prevalence patterns across age and sex were similar to those reported in community epidemiology studies, although, not unexpectedly, the overall rates were somewhat lower. Primary care providers identified a substantial proportion of the youth with a mood disorder. Antidepressant medication was used more often by youth identified with a mood disorder in medical care settings than by those youth identified in specialty mental health care settings. These results are valuable in determining if youth with mood disorders receiving medication prescriptions across settings are treated according to current best practice guidelines (such as the adult depression guidelines [U.S. Department of Health and Human Services, 1993]), that is, primarily with SSRI medications.

Mediating mechanisms in a program to reduce intentions to use anabolic steroids and improve exercise self-efficacy and dietary behavior

This study investigated the mediating mechanisms responsible for the effects of a program designed to reduce intentions to use anabolic steroids, improve nutrition, and increase strength training self-efficacy. Fifteen of 31 high school football teams (N = 1,506 players at baseline) in Oregon and Washington were assigned to receive the intervention. The multicomponent program addressed the social influences promoting ergogenic drug use and engaging students in healthy nutrition and strength training alternative behaviors. Although the results differed across the three dependent variables, the program appeared to work by changing team norms. Unlike prevention of other drugs, changes in knowledge and perceived severity were mediators of program effects in this study.

Psychiatric hospitalizations, arrests, emergency room visits, and homelessness of clients with serious and persistent mental illness: findings from a randomized trial of two ACT programs vs. usual care

OBJECTIVE

This investigation examined several adverse outcomes in clients with serious mental illness in a randomized trial of Assertive Community Treatment (ACT) versus usual care.

METHOD

163 subjects were randomized to one of two ACT experimental conditions (staffed by consumers or non-consumers) or usual community care. Conditions were compared on psychiatric hospitalization, emergency room visit, arrest, and homelessness, within the two-year study period. Demographic, program, and client variables were examined for significant associations with outcomes.

RESULTS

Significant differences were found between ACT and usual care in time to first arrest, but not hospitalization, homelessness or ER visits. Shorter time to first hospitalization was associated with male gender, diagnoses other than schizophrenia, high psychiatric symptomatology and lower provider case load. ER visits were associated with increased client symptomatology. Shorter times to homelessness were predicted by poorer therapeutic alliance between case manager and clients. Shorter time to first arrest was predicted by client minority status and enrollment in usual care.

CONCLUSIONS

The paucity of significant main effects may have been due to a prolonged "start-up" phase of the ACT programs, poor ACT implementation, restricted availability of psychiatric hospital beds, or changes in usual care services delivered over the study period.

Feasibility of surveillance of changes in human fertility and semen quality

To show that male fertility is declining is not simple. Few men volunteer and recruitment bias may lead to over-representation of the subfertile. Semen analysis has errors arising from counting and poorly standardized criteria, which may be overcome by automation. Time to pregnancy (TTP)-the number of menstrual cycles taken to conceive-measures fertility and allows male recruitment bias to be estimated. We review automated measurement of sperm concentration, motility and morphology and present a preliminary report on a study to assess a retrospective TTP questionnaire, recruitment bias and feasibility for large-scale surveillance of fertility.

An important role of actin polymerization in the human zona pellucida-induced acrosome reaction

The effects of inhibitors of actin polymerization and depolymerization, cytochalasins and phalloidin, on the human zona pellucida (ZP)-induced acrosome reaction (AR) were investigated. Motile spermatozoa, selected by swim-up technique from normozoospermic men, were incubated in medium with or without the actin modulators. Oocytes (four per test) which had failed to fertilize in vitro were added and incubation continued for 2 h. The spermatozoa bound to the ZP were dislodged by repeatedly aspirating the oocytes with a small-bore pipette and the status of the acrosomes was determined by fluorescein-labelled Pisum sativum agglutinin (PSA). Double immunofluorescent staining with PSA and an anti-actin monoclonal antibody illuminated the acrosomal region of acrosome-intact spermatozoa. In calcium ionophore-induced AR spermatozoa, actin staining was confined to the equatorial segment, post-acrosomal region and tail. Cytochalasins B and D significantly inhibited ZP-induced AR in a dose-dependent manner (P < 0.001). Both inhibitors had no effect on the acrosome of spermatozoa in the insemination medium. Cytochalasin B or D (10-40 micromol/l) had no effect on total percentage motile spermatozoa but decreased sperm velocity and hyperactivation. Phalloidin had no effect on the ZP-induced AR or sperm motility. In conclusion, actin polymerization plays an important role in human ZP-induced AR.

Psychosocial treatments for adolescent depression

Major Depressive Disorders affect between 2% and 5% of adolescents at any one point in time. Depression in adolescence is associated with serious psychosocial deficits and has negative effects on functioning during young adulthood. Starting with the pioneering work of Lenore Butler and her colleagues, many psychosocial interventions have been developed and studied, with generally positive results. On the basis of a meta-analysis of the existing cognitive-behavioral therapy (CBT) studies we estimate an overall effect size of 1.27 and that 63% of patients show clinically significant improvement at the end of treatment. It seems reasonable to conclude that CBT has been demonstrated to be an effective treatment for depressed adolescents. In this article we describe these interventions, most of which are meant to address the problems shown by depressed adolescents. The purpose of our article is to bring this literature to the attention of clinicians in a manner which quickly and clearly summarizes the key features of the interventions to make it easy for clinicians to take advantage of this wealth of information and to avail themselves of the existing resources. We conclude by suggesting future directions and several additional areas of application for adolescent depression treatments.

Cognitive-behavioral treatment of adolescent depression: efficacy of acute group treatment and booster sessions

OBJECTIVE

This trial examined the effects of both acute and maintenance cognitive-behavioral therapy (CBT) for depressed adolescents.

METHOD

Adolescents with major depression or dysthymia (N = 123) were randomly assigned to 1 of 3 eight-week acute conditions: adolescent group CBT (16 two-hour sessions); adolescent group CBT with a separate parent group; or waitlist control. Subsequently, participants completing the acute CBT groups were randomly reassigned to 1 of 3 conditions for the 24-month follow-up period: assessments every 4 months with booster sessions; assessments only every 4 months; or assessments only every 12 months.

RESULTS

Acute CBT groups yielded higher depression recovery rates (66.7%) than the waitlist (48.1%), and greater reduction in self-reported depression. Outcomes for the adolescent-only and adolescent + parent conditions were not significantly different. Rates of recurrence during the 2-year follow-up were lower than found with treated adult depression. The booster sessions did not reduce the rate of recurrence in the follow-up period but appeared to accelerate recovery among participants who were still depressed at the end of the acute phase.

CONCLUSIONS

The findings, which replicate and expand upon a previous study, support the growing evidence that CBT is an effective intervention for adolescent depression.

Quantitative sperm mucus penetration: modified formulae for calculating penetration efficiency

In 1980 Katz et al. derived a formula for the percentage of successful collisions (PSC) as a quantitative measure of sperm-cervical mucus penetration efficiency. The use of PSC waned after its validity was questioned by reports of values >100% and the observation that PSC varied with the cross-sectional area of the mucus column. The aim of the present study was to develop a more accurate measure of mucus penetration efficiency by correcting the original formula for the effects of sperm depletion in the semen reservoir. Two formulae were derived using different models for the sperm-mucus interaction: (i) each motile spermatozoon was assumed to have an equal chance of mucus penetration on collision; (ii) a select subpopulation of spermatozoa was assumed to penetrate with 100% efficiency on collision. Both modified formulae gave PSC values higher than the original estimates. Under the experimental conditions employed in this work, where large capillaries were used, the depletion corrections ranged from 4 to 46% (n=8, mean 20%) for model (i) and from 190 to 320% (n=8, mean 250%) for model (ii). The invariance of PSC (ii) results with respect to capillary cross-sectional area (1.52 mm2, 31.1%; 5.4 mm2, 28.2%) suggests that the assumptions of model (ii) provide the more accurate description of the sperm-mucus interaction.

A simple monthly means chart system for monitoring sperm concentration

A simple, robust monthly means chart system for monitoring sperm concentration was developed and used in our andrology laboratory. The system relied on the central limit theorem to allow estimation of chart limits without resorting to data transformation procedures. Once the chart was drawn up, the arithmetic mean of sperm concentration was determined monthly and plotted. Monthly means which fell outside 2 SE from the baseline mean were investigated. Initial experience with this chart system suggests that it provides a simple and useful quality assurance method which should be applicable to other semen variables such as motility and sperm morphology.

Assertive community treatment versus usual care in engaging and retaining clients with severe mental illness

OBJECTIVE

Two assertive community treatment teams were compared with a usual-care control condition based on their ability to engage and retain clients with serious and persistent mental illness in community-based mental health services.

METHODS

Clients were randomly assigned to one of two assertive community treatment teams (N = 116) or to usual care (N = 58). Survival analysis was used to compare clients' length of engagement and retention in service in the two treatment conditions and in usual care. Cox regression analyses were conducted to determine whether demographic, program, or client variables were significantly associated with length of retention in treatment. Data on these baseline variables were collected after clients made initial contact with their community mental health provider. Clients were observed for up to 870 days.

RESULTS

By the end of the observation period, the assertive community treatment teams retained 68 percent of their clients, compared with 43 percent in usual care. In both types of treatment, clients were at greatest risk of dropping out of services during the first nine months. The risk of dropout was associated with the type of treatment. Usual-care clients were more than twice as likely as assertive community treatment clients to drop out for reasons related to dissatisfaction with treatment. Each additional night homeless during the six months before enrollment in the study resulted in a 14 percent increase in the probability of dropout.

CONCLUSIONS

Assertive community treatment clearly demonstrated a greater ability than usual care services to engage and retain clients in community mental health care.

Intracytoplasmic sperm injection for treating infertility associated with sperm autoimmunity

OBJECTIVE

To determine whether intracytoplasmic sperm injection (ICSI) can be used to achieve normal fertilization, embryo cleavage, and pregnancies in cases of sperm autoimmunity.

DESIGN

A retrospective analysis of ICSI results in sperm antibody-positive and randomly selected antibody-negative groups.

SETTING

University- and hospital-based reproductive research laboratory and tertiary referral IVF program.

PATIENT(S)

Thirty-nine couples selected on the basis of a strongly positive result for sperm antibodies of immunoglobulin (Ig) G and/or IgA immunoglobulin class in the male partner and a control group of 140 antibody-negative couples.

INTERVENTION(S)

Human menopausal gonadotropin, hCG and Lucrin (Abbott Australasia, Kurnell, NSW, Australia) were given by injection. Oocyte collection was by transvaginal ovarian puncture. Blood was collected for beta-hCG measurement.

MAIN OUTCOME MEASURE(S)

Normal fertilization, embryo cleavage, establishment of clinical pregnancy, and delivery.

RESULT(S)

There were no significant differences in fertilization rates (62% versus 58%) or clinical pregnancy rates (19% versus 12%) between sperm antibody-positive and sperm antibody-negative patient groups.

CONCLUSION

Intracytoplasmic sperm injection is an effective treatment for patients with severe sperm autoimmunity.

A simplified quantitative cervical mucus penetration test

A simplified quantitative cervical mucus penetration test was developed and applied to the semen of 21 prospective donors in order to evaluate its performance. Analysis of the data using stepwise multiple regression revealed that the concentration of spermatozoa in mucus was related primarily to the concentration of progressive spermatozoa in the semen (63% of variance explained), and secondarily to the average path velocity of spermatozoa in semen (70% of variance explained by a model incorporating both variables). However, consistent with previous studies, the derived indices of penetration efficiency including the percentage successful collisions (PSC), percentage successful entries (PSE) and the motile density ratio (MDR) were not significantly correlated with any of the semen variables examined, although multiple regression did derive models which explained 27-31% of the variance in these three dependent variables. The strong correlation and correspondence between the PSC and the MDR suggests that the latter may provide a simplified index of penetration efficiency for routine clinical use and further research in this area.

Artificial insemination and in-vitro fertilization using donor spermatozoa: a report on 15 years of experience

Donor insemination (DI) using cryopreserved semen commenced at The Royal Women's Hospital in 1976. Over the next 15 years we performed 5953 treatment cycles to achieve 816 pregnancies (13.7% per cycle) and 706 live births. In-vitro fertilization (IVF) using donor spermatozoa commenced in 1986. Over the next 5 years we performed 303 treatment cycles for 185 couples. Including subsequent transfer of cryopreserved embryos, a total of 33% of couples achieved a successful pregnancy by IVF. Statistical analysis indicated that, for DI pregnancies, the most important semen variable was the percentage post-thaw motility, whilst for normal fertilization in IVF it was the pre-freeze motility. These results may be explained by the compensatory effects of post-thaw processing of spermatozoa for IVF, but not for DI in our clinic.

Does PTSD transcend cultural barriers? A study from the Khmer Adolescent Refugee Project

OBJECTIVE

To determine whether the factor structure of the posttraumatic stress disorder (PTSD) syndrome in Cambodian refugee youth resembles earlier reported factor studies in Caucasian samples.

METHOD

194 Khmer adolescent refugees who reported prior significant trauma (most of it massive war trauma as children) were administered the PTSD module of the Diagnostic interview for Children and Adolescents, as part of an epidemiological study on the effects of war on this group of refugees.

RESULTS

The following four factors were found: arousal, avoidance, intrusion, and numbing. A confirmatory factor analysis using data from the parents of this sample yielded a good fit for the four-factor solution based on the youth data.

CONCLUSIONS

The four-factor solution from this sample resembled earlier studies on traumatized Caucasian and African-American adults. These results lend further credibility to the veracity of this diagnosis with refugee samples. PTSD as a result of prior war trauma appears to surmount the barriers of culture and language in this sample.

The Adolescents Training and Learning to Avoid Steroids (ATLAS) prevention program. Background and results of a model intervention

OBJECTIVE

To develop and test a school-based intervention to prevent anabolic androgenic steroid use among high-risk adolescent athletes.

DESIGN

Nonrandom controlled trial.

SETTING

Two urban high schools.

PARTICIPANTS

Fifty-six adolescent football players at the experimental school and 24 players at the control school.

INTERVENTION

Eight weekly, 1-hour classroom sessions delivered by the coach and adolescent team leaders, and eight weight-room sessions delivered by research staff. The intervention addressed sports nutrition and strength training as alternatives to steroid use, drug refusal role play, and antisteroid media campaigns.

OUTCOME MEASURES

A preintervention and postintervention questionnaire that assessed attitudes toward and intent to use steroids and other drugs; knowledge of drug effects; and diet, exercise, and related constructs.

RESULTS

Compared with controls, experimental subjects were significantly less interested in trying steroids after the intervention, were less likely to want to use them even if their friends used them, were less likely to believe steroid use was a good idea, believed steroids were more dangerous, had better knowledge of alternatives to steroid use, had improved body image, increased their knowledge of diet supplements, and had less belief in these supplements as beneficial.

CONCLUSIONS

Significant beneficial effects were found despite the sample size, suggesting that the effects of the intervention was large. This outcome trial demonstrates an effective anabolic androgenic steroid prevention program for adolescent athletes, and the potential of team-based interventions to enhance adolescents' health.

The Khmer Adolescent Project: III. A study of trauma from Thailand's Site II refugee camp

OBJECTIVE

To determine the prevalence rates of posttraumatic stress disorder (PTSD) and depression in a sample of 99 Cambodian youths, aged 18 to 25 years, living in the Site II refugee camps along the Thai-Cambodian border; to compare these rates to data collected in a similarly aged sample of Cambodian refugees living in the United States; and to illustrate the findings with case vignettes and a brief description of the refugee camp at Site II.

METHOD

The senior author describes the main features of life in the Site II camp while being employed in one of its medical clinics. A Khmer translated version of the depression section of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of Diagnostic Interview Schedule for Children and Adolescents were used in interview format by trained bilingual research assistants. Khmer versions of the Beck Depression Inventory and the Impact of Events Scale were also administered.

RESULTS

The enduring nature of PTSD was evident in this sample of Khmer youths who had survived the Pol Pot regime as children. Similar rates of Pol Pot-related PTSD were found when compared to rates from the US sample. Subclinical forms of PTSD were found in those who reported their worst trauma during life in the camp, while the full PTSD syndrome was associated with those who reported trauma occurring during the earlier Pol Pot regime. Extremely high rates of depressive disorder were found which were interpreted as related to the repatriation back to Cambodia as this study was undertaken.

CONCLUSION

PTSD in this sample appears to be specifically related to earlier war trauma, while depressive symptoms appear more related to recent stressors. As with other findings from the Khmer adolescent project, this study reaffirms the strong connection between the diagnosis of current PTSD and earlier war trauma in an additional sample of youths at Site II, Thailand. Depressive symptoms, on the other hand, appear to be related to the vicissitudes of recent stressful events in this refugee population.

Multiple forms of stress in Cambodian adolescent refugees

A sample of 170 Cambodian youth and 80 of their mothers were interviewed regarding DSM-III-R diagnoses of Post Traumatic Stress Disorder (PTSD) and depressive disorders, and the stress of war trauma, resettlement, and recent life events. A consistent relation between earlier war trauma, resettlement stress, and symptoms of PTSD was found. In contrast, the strongest relation with depressive symptoms was found for recent stressful events. Despite the long interval of time since the occurrence of the war trauma, these youth and their parents reported these experiences in a highly consistent fashion. PTSD and depression in refugee youth appear to be different conditions following different pathways during adolescent development.

Improving the transition from basic efficacy research to effectiveness studies: methodological issues and procedures

This article proposes methodological strategies that, if used in treatment outcome research, may help in the transition of efficacy research findings into effectiveness trials in clinical and service delivery settings. Alternative methodologies are proposed to examine how treatment effectiveness may vary as a function of degree of treatment structure, treatment protocol compliance, psychotherapy integration into an overall treatment regimen, participant selection and composition, and variations in treatment parameters. The discussion focuses on encouraging the retention of experimental control while stretching psychotherapy outcome research designs to encompass effectiveness issues.

Improving the transition from basic efficacy research to effectiveness studies: methodological issues and procedures

This article proposes methodological strategies that, if used in treatment outcome research, may help in the transition of efficacy research findings into effectiveness trials in clinical and service delivery settings. Alternative methodologies are proposed to examine how treatment effectiveness may vary as a function of degree of treatment structure, treatment protocol compliance, psychotherapy integration into an overall treatment regimen, participant selection and composition, and variations in treatment parameters. The discussion focuses on encouraging the retention of experimental control while stretching psychotherapy outcome research designs to encompass effectiveness issues.

Posttraumatic stress disorder across two generations of Cambodian refugees

OBJECTIVE

To examine the expression of war-related trauma as manifested by DSM-III-R rates of posttraumatic stress disorder (PTSD) and major depressive disorder in two generations of Cambodian refugees living in the western United States.

METHOD

A probability sample of 209 Khmer adolescents and one of their parents were interviewed using portions of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Epidemiologic Version and the PTSD section of the Diagnostic Interview for Children and Adolescents. Interviews were conducted in English by a master's-level clinician with a Khmer interpreter.

RESULTS

PTSD was found to be significantly related across parent-child generations. A nonsignificant generational trend was also found for depressive disorders. A number of environmental variables measured in the study (amount of reported war trauma, loss, living arrangements, treatment received, socioeconomic status) were not related to these findings. Parents were more likely to report an earlier onset of PTSD symptoms.

CONCLUSIONS

This study suggests that PTSD in refugees may cluster in families. Whether this phenomenon is caused by a genetic susceptibility to trauma awaits further research. PTSD and depressive disorders in refugee populations, while often comorbid, appear to follow different courses over time.

Immunoinfertility: a case study with implications for immunocontraception

A detailed case history was compiled on a couple who have had primary infertility for more than 20 years. The history and further laboratory investigations indicated that the infertility was caused by high-titre sperm antibodies in the female. The antibodies blocked sperm-zona binding and reacted with a prominent band at 65 kD in Western blots. Preliminary studies indicate that a subset of the patient's antibodies are specific for a unique protein sequence expressed by a cDNA testis library. This antigen may have potential for immunocontraceptive vaccine development.

Normal fertilization and embryo development by intracytoplasmic sperm injection of round-headed acrosomeless sperm

OBJECTIVE

To investigate the ability of round-headed acrosomeless sperm to bind to the human zona pellucida (ZP) and oolemma and to fertilize human oocytes by intracytoplasmic sperm injection.

DESIGN

Oocytes that had failed to fertilize in IVF were used for sperm-ZP and spermoolemma binding tests. Sperm from a fertile donor was used as a control for oocyte variability. Intracytoplasmic sperm injection was used for assisted fertilization.

SETTING

University- and hospital-based reproductive research laboratory and tertiary referral IVF program.

PATIENTS

Case study of a couple in which the man has 100% round-headed acrosomeless sperm in the ejaculate.

MAIN OUTCOME MEASURE

Fertilization and embryo development and the ability of sperm to bind to the ZP and oolemma.

RESULTS

No ZP or oolemma binding was achieved, but normal fertilization and embryo development was obtained after intracytoplasmic injection of round-headed acrosomeless sperm. However, no pregnancy was achieved after the transfer of two cleaving embryos.

CONCLUSIONS

Normal fertilization and embryo development from round-headed acrosomeless sperm is possible with intracytoplasmic sperm injection. However, it remains to be reported whether pregnancy can result from fertilization with this type of sperm defect.

Assessment of the Sperm Quality Analyzer

OBJECTIVE

To assess the relationship between the results of the Sperm Quality Analyzer (United Medical Systems Inc., Santa Ana, CA), which measures motile sperm concentration by light scattering, conventional manual semen analysis characteristics, and computer-assisted sperm motility analyses.

DESIGN

Sperm Quality Analyzer measurements and manual and computer-assisted semen analyses were performed on 150 (50, 62, and 38) samples in three laboratories and the results were compared.

SETTING

The study was performed in the Andrology Laboratory of Prince Henry's Institute of Medical Research, Monash Medical Centre, and Andrology Laboratory and Reproductive Biology Unit at the Royal Women's Hospital, Melbourne, Victoria, Australia.

PATIENTS

Patients presented to the laboratories for routine fertility evaluation in the male and were selected at random to reflect the range of normal and abnormal samples seen in the laboratories.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Sperm count, motility (percent motility, motility index, velocity, and amplitude of lateral head displacement [ALH]), morphology, and normal acrosomes were evaluated by manual and computer-assisted semen analysis and sperm quality analyzer motility index.

RESULTS

Spearman nonparametric univariate analysis showed strong correlations between sperm motility index and manual sperm concentration, motility, abnormal morphology, and normal acrosomes by Pisum sativum agglutinin; and computer-assisted sperm motility analysis sperm concentration, motile concentration, and percent static. Curvilinear velocity, straight-line velocity (VSL), and linearity also were related significantly to sperm motility index values. By multiple regression analysis, the significant covariates of the sperm motility index were motile sperm concentration, abnormal morphology, ALH, and straight-line velocity and these accounted for 85.5% of the variance of the sperm motility index.

CONCLUSIONS

The Sperm Quality Analyzer is easy to use. The good correlation between the sperm motility index, motile sperm concentration, and, in addition, a number of other semen parameters supports the use of the Sperm Quality Analyzer for screening patients and in situations that warrant a rapid verification of semen quality, such as in the IVF or artificial insemination clinic. Further investigation of the Sperm Quality Analyzer in the management of male infertility is warranted.

The Khmer Adolescent Project. II: Functional capacities in two generations of Cambodian refugees

A sample of 206 adolescent Cambodian youth and 159 of their parents were interviewed to determine the extent of their past war trauma during the Pol Pot regime in Cambodia (1975-1979), their resettlement stress, their current diagnostic status, and their functional ability as refugees in the United States. This report focuses on the last of these aims. Overall, these youth were found to be functioning quite well. Their diagnostic status did not relate strongly to their functional status. Parents showed a stronger relationship between diagnostic status and measures of functioning than did adolescents. The implications of these findings for future studies are discussed.

Targeted prevention of unipolar depressive disorder in an at-risk sample of high school adolescents: a randomized trial of a group cognitive intervention

OBJECTIVES

This investigation attempted to prevent unipolar depressive episodes in a sample of high school adolescents with an elevated risk of depressive disorder.

METHOD

Adolescents at risk for future depressive disorder by virtue of having elevated depressive symptomatology were selected with a two-stage case-finding procedure. The Center for Epidemiologic Studies-Depression Scale (CES-D) was administered to 1,652 students; adolescents with elevated CES-D scores were interviewed with the Schedule for Affective Disorders and Schizophrenia for School-Age Children. Subjects with current affective diagnoses were referred to nonexperimental services. The remaining 150 consenting subjects were considered at risk for future depression and randomized to either a 15-session cognitive group prevention intervention or an "usual care" control condition. Subjects were reassessed for DSM-III-R diagnostic status after the intervention and at 6- and 12-month follow-up points.

RESULTS

Survival analyses indicated a significant 12-month advantage for the prevention program, with affective disorder total incidence rates of 14.5% for the active intervention, versus 25.7% for the control condition. No differences were detected for nonaffective disorders across the study period.

CONCLUSION

Depressive disorder can be successfully prevented among adolescents with an elevated future risk.

Sperm preparation for intracytoplasmic injection: methods and relationship to fertilization results

Sperm preparation for intracytoplasmic sperm injection (ICSI) is described and the effect of high speed centrifugation during preparation on fertilization rate is evaluated. No significant differences were found in the 2-pronuclear or abnormal fertilization rates between sibling oocytes injected with sperm prepared by swim-up or mini-Percoll combined with high speed centrifugation. The high fertilization rate obtained with both methods indicates that high speed centrifugation is not necessary to prepare sperm for ICSI. Fertilization rates were also compared for sperm obtained from ejaculates, fresh and frozen epididymal aspirates, and testicular biopsies. High fertilization rates were obtained from all groups but they were significantly higher in those oocytes injected with epididymal sperm (78% per oocyte surviving injection). The high fertilization rate with epididymal sperm may reflect sperm quality or may result from the method of sperm preparation for injection. Fertilization after the injection of sperm from which the tail was dislodged during immobilization was compared with that obtained using intact sperm. A significantly lower rate of 2-pronuclear fertilization was found in those oocytes injected with sperm heads only (55%) compared with intact sperm (68%), although cleavage rates between the two groups were similar. The use of hypo-osmotic medium to select potentially live sperm from an immotile sample is also described and fertilization was obtained after the injection of sperm with a structural defect which were selected using this technique. These results indicate that high fertilization rates can be obtained with ejaculated, epididymal and testicular sperm without special treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of anticlusterin monoclonal antibodies for the combined assessment of human sperm morphology and acrosome integrity

Clusterin is an abundant protein in the human male reproductive tract which appears to be produced by the testis, epididymis and the seminal vesicles. Using monoclonal antibodies and an amplified immunoperoxidase technique, we have identified two apparently biochemically distinct forms of clusterin on human spermatozoa. Morphologically abnormal spermatozoa have an extensive surface coating of conventional 80 kDa native clusterin, but this form of clusterin is not detectable on normal spermatozoa. Normal spermatozoa, however, contain within the acrosomal cap a different form of clusterin, reactive with an anticlusterin alpha-chain antibody. Agglutinated spermatozoa, most of which are grossly abnormal, were intensely labelled with the antibody against conventional 80 kDa clusterin, suggesting that the 'clustering' properties of this protein may play a role in the aggregation of abnormal spermatozoa. Anticlusterin monoclonal antibodies may be useful for semen analysis. Staining spermatozoa with anticlusterin monoclonal antibodies is a technically simple method which provides a visually obvious means of assessing spermatozoa morphology and acrosome status simultaneously. The current data also suggest that different functions of clusterin in the reproductive tract may be attributed to different molecular forms of the protein.