Derri L. Shtasel

Gender differences in the clinical expression of schizophrenia

Gender differences have been reported for a variety of clinical measures in patients with schizophrenia. Clinical characterization may be helpful in identifying symptom clusters which can then be linked to underlying brain function. In this study 74 men and 33 women meeting DSM-IIIR criteria for schizophrenia were studied off medication and rated on measures of symptom type and severity, as well as premorbid and current function. Men were more severely impaired in ratings of negative symptoms, while positive symptoms were not significantly different. There were also differences in premorbid and current functioning, with women manifesting better social functioning than men.

Out on the street: a public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless.

A disproportionate number of lesbian, gay, bisexual, and transgender (LGBT) youth experience homelessness each year in the United States. LGBT youth who are homeless have particularly high rates of mental health and substance use problems, suicidal acts, violent victimization, and a range of HIV risk behaviors. Given the intense needs of LGBT youth experiencing homelessness, it is imperative to understand their unique experiences and develop responsive practices and policies. The range and severity of health risks vary across subgroups of all homeless LGBT youth, and because the population is nonhomogeneous, their particular needs must be identified and addressed. Thus, the purpose of this article is to review the causes of homelessness among LGBT youth, discuss the mental health and victimization risks faced by this population, address differences among homeless LGBT subgoups, and recommend effective interventions and best practices. The authors conclude by discussing promising future research and public policy directions.

Cerebral blood flow in schizophrenia: Effects of memory processing on regional activation

Regional cerebral blood flow (rCBF) was measured with the 133Xenon clearance technique and a high resolution (254 detectors) scanner during the performance of a verbal and a facial memory task in 18 patients with schizophrenia and 18 sociodemographically matched controls. Patients and controls had comparable resting rCBF, but differed in global and hemispheric rCBF changes induced by the memory tasks. Patients had less global increase, which was relatively higher in the left hemisphere, and this was more pronounced for the verbal task. Although controls showed appropriate laterality changes (L > R for verbal and R > L for facial memory) in the midtemporal region, patients failed to show such a focal pattern. They did not show appropriate laterality change in the midtemporal region, but instead showed such changes in other regions. Patients showed greatest impairment in specificity of verbal recognition performance, and this correlated with severity of hallucinations and delusions. This supports a model of left temporal lobe dysfunction in schizophrenia.

Effects of Memory Processing on Regional Brain Activation: Cerebral Blood Flow in Normal Subjects

The role of the temporal lobe in memory has been implicated in lesion studies, which have also suggested the hypothesis of greater left hemispheric involvement in verbal, and right hemispheric involvement in facial memory. We tested these hypotheses in a sample of 27 normal right-handed subjects using the 133Xenon clearance method for measuring cerebral blood flow (CBF). The CBF was measured during resting baseline, word recognition, and face recognition conditions in counterbalanced order. CBF increased during recognition compared to baseline, and for the midtemporal lobe this increase was asymmetric to the left hemisphere for words and to the right for faces. While overall CBF levels and task related increases in CBF were uncorrelated either with performance or with delta performance (excess performance relative to basal memory abilities), laterality of task-related CBF correlated with both performance indices, showing regional specificity of correlations. This neurobehavioral probe paradigm can be applied in the study of neural substrates of normal and disturbed memory.

Magnetic resonance imaging in schizophrenia: relationship with clinical measures

Relationships were examined between clinical features of schizophrenia and cerebrospinal fluid (CSF) volume in brain obtained by magnetic resonance imaging (MRI) in a sample of 59 patients. The volumes of the cerebral hemispheres and CSF were measured with a computer program designed to separate reliably neural tissue from CSF. The CSF to cranial volume ratios were related to history, symptom profile and outcome functioning. Earlier age of onset was associated with higher sulcal CSF ratio, r = -0.40. The anatomic measures were unrelated to symptom severity. However, patient subtypes differed in the laterality of measures. Higher left hemispheric ratios were seen in patients with severe negative symptoms, and left predominance of ventricular relative to sulcal ratios was associated with the presence of hallucinations and delusions. The results suggest that while higher CSF is related to earlier age of onset, the clinical symptoms are more related to its lateralization. This is consistent with the hypothesis that schizophrenia is a lateralized brain disease.

Effects of medication history on midlatency auditory evoked responses in schizophrenia

The recovery cycle of the P1 component of the auditory evoked potential (50-70 ms latency) has been reported as abnormal in both unmedicated and medicated patients with schizophrenia when a paired stimuli protocol is used to examine recovery. However, findings have been mixed when a stimulus train protocol is used. This study examined the effects of medication history on P1 abnormalities in schizophrenia assessed by a stimulus train protocol. Auditory evoked potentials were recorded from 14 normal controls, 14 neuroleptic naive patients with schizophrenia and 14 previously medicated patients in response to binaural clicks presented at three stimulus rates: 1/s, 5/s and 10/s. Neuroleptic naive patients showed a smaller P1 at the baseline rate (1/s) and greater recovery (less amplitude suppression) at faster rates than did normal controls or previously medicated patients. Additional analyses suggested that this latter effect was not due to smaller baseline P1 amplitudes. Greater recovery in neuroleptic naive patients was not associated with clinical symptomatology contrary to previous findings of the authors for a mixed sample of neuroleptic naive and previously medicated patients. Medication status appears to account for some of the variability in P1 abnormalities in schizophrenia although identification of the underlying mechanism responsible requires further study.

Psychiatry in the Harvard Medical School—Cambridge Integrated Clerkship: An Innovative, Year-Long Program

ObjectiveThe authors present what is to their knowledge the first description of a model for longitudinal third-year medical student psychiatry education.MethodA longitudinal, integrated psychiatric curriculum was developed, implemented, and sustained within the Harvard Medical School-Cambridge Integrated Clerkship. Curriculum elements include longitudinal mentoring by attending physicians in an outpatient psychiatry clinic, exposure to the major psychotherapies, psychopharmacology training, acute psychiatry “immersion” experiences, and a variety of clinical and didactic teaching sessions.ResultsThe longitudinal psychiatry curriculum has been sustained for 8 years to-date, providing effective learning as demonstrated by OSCE scores, NBME shelf exam scores, written work, and observed clinical work. The percentage of students in this clerkship choosing psychiatry as a residency specialty is significantly greater than those in traditional clerkships at Harvard Medical School and greater than the U.S. average.ConclusionLongitudinal integrated clerkship experiences are effective and sustainable; they offer particular strengths and opportunities for psychiatry education, and may influence student choice of specialty.

Caring for Homeless Persons with Serious Mental Illness in General Hospitals

BACKGROUND The care of homeless persons with serious mental illness remains a common and challenging problem in general hospital settings. OBJECTIVE This article aims to review data on homelessness and its psychiatric comorbidities, and to expand the skills of providers who encounter homeless individuals in general hospital settings. RESULTS Literature review reveals patient, provider, and systems factors that contribute to suboptimal health outcomes in homeless individuals. CONCLUSIONS Diagnostic rigor, integrated medical and psychiatric care, trauma-informed interventions, special considerations in capacity evaluations, and health care reform initiatives can improve the treatment of homeless persons with serious mental illness.

Primary Care Provider Practices and Perceptions Regarding HPV Vaccination and Anal Cancer Screening at a Boston Community Health Center

Human papillomavirus (HPV) vaccination and anal cancer screening are valuable, yet underutilized, tools in prevention of HPV-related cancers among sexual and gender minority (SGM) populations. The aim of this study was to characterize primary care providers’ (PCPs) practices and perceptions pertaining to HPV vaccination and anal cancer screening. A survey assessing self-reported practice characteristics related to HPV vaccination and anal cancer screening, as well as perceived barriers to vaccination and anal cancer screening at the patient-, provider-, and system-level was distributed to PCPs at a Federally-Qualified Health Center that specializes in care for SGM populations in the greater Boston area. A total of 33 PCPs completed the survey. All PCPs strongly recommended HPV vaccination to their patients by emphasizing that the vaccine is extremely important or very important. Most PCPs told their patients that the HPV vaccine prevents cervical cancer (96.9%), anal cancer (96.9%), oropharyngeal cancer (72.7%), penile cancer (57.5%), and genital warts (63.6%). There is substantial variability among providers regarding recommendations for anal cancer screening and follow-up. Most PCPs perceived that patient-level factors such as poverty, mental illness, and substance use disorders were barriers to HPV vaccination and anal cancer screening. Systems-level barriers such as lack of clinical time with each patient and lack of staffing were also described as barriers to vaccination and screening. Patient-, provider- and systems-level improvements are important to increase HPV vaccination and anal cancer screening rates.

Residential segregation and mental health among Latinos in a nationally representative survey

Background Among Latinos, living in a locality with greater Latino ethnic density may be protective for mental health, although findings vary by Latino subgroup, gender and birthplace. Although little studied, Latino residential segregation may capture different pathways linking risk and protective environmental factors to mental health than local ethnic density. Methods This study evaluated the association between residential segregation and mental distress as measured by the Kessler-10 (K10) among Latino participants in the National Latino and Asian American Study (NLAAS). Census data from 2000 was used to calculate metropolitan statistical area (MSA) residential segregation using the dissimilarity and isolation indices, as well as census tract ethnicity density and poverty. Latino subgroup (Puerto Rican, Mexican American, Cuban American and other Latino subgroup), gender and generation status were evaluated as moderators. Results Among 2554 Latino participants in NLAAS, residential segregation as measured by the isolation index was associated with less mental distress (β −0.14, 95% CI −0.26 to −0.03 log(K10)) among Latinos overall after adjustment for ethnic density, poverty and individual covariates. Residential segregation as measured by the dissimilarity index was significantly associated with less mental distress among men (β −0.56, 95% CI −1.04 to −0.08) but not among women (β −0.20, 95% CI −0.45 to 0.04, p-interaction=0.019). No modification was observed by Latino subgroup or generation. Conclusions Among Latinos, increasing residential segregation was associated with less mental distress, and this association was moderated by gender. Findings suggest that MSA-level segregation measures may capture protective effects associated with living in Latino communities for mental health.