Donna Ames

Attentional modulation of the P50 suppression deficit in recent-onset and chronic schizophrenia.

Schizophrenia is associated with deficits in P50 suppression to the second stimulus in a pair, a process often conceptualized as a preattentive index of sensory gating. This study assessed the malleability of the deficit by determining whether early attentional control can influence P50 gating across different phases of schizophrenia. Participants included 28 patients in the recent-onset (n = 16) or chronic (n = 12) phase of illness and 28 healthy comparison subjects. During the standard paradigm, chronic schizophrenia patients exhibited impaired P50 suppression relative to healthy subjects, whereas recent-onset schizophrenia patients were intermediate. Directing voluntary attention toward the initial stimulus yielded substantial improvements in the P50 ratio; recent-onset schizophrenia patients achieved ratio scores comparable to those of healthy participants, whereas chronic patients also improved and could no longer be distinguished clearly from the healthy comparison sample. Directing attention toward the second stimulus enhanced P50 amplitude to the second stimulus across groups, possibly because activation of the inhibitory mechanism was overridden or circumvented by task demands. Thus, P50 suppression may be primarily preattentive under standard conditions, but manipulation of early attention can exert a modulatory influence on P50, indicating that the suppression deficit is malleable in schizophrenia without pharmacological agents.

Comparison of SGA Oral Medications and a Long-Acting Injectable SGA: The PROACTIVE Study

Until relatively recently, long-acting injectable (LAI) formulations were only available for first-generation antipsychotics and their utilization decreased as use of oral second-generation antipsychotics (SGA) increased. Although registry-based naturalistic studies show LAIs reduce rehospitalization more than oral medications in clinical practice, this is not seen in recent randomized clinical trials. PROACTIVE (Preventing Relapse Oral Antipsychotics Compared to Injectables Evaluating Efficacy) relapse prevention study incorporated efficacy and effectiveness features. At 8 US academic centers, 305 patients with schizophrenia or schizoaffective disorder were randomly assigned to LAI risperidone (LAI-R) or physicians choice oral SGAs. Patients were evaluated during the 30-month study by masked, centralized assessors using 2-way video, and monitored biweekly by on-site clinicians and assessors who knew treatment assignment. Relapse was evaluated by a masked Relapse Monitoring Board. Differences between LAI-R and oral SGA treatment in time to first relapse and hospitalization were not significant. Psychotic symptoms and Brief Psychiatric Rating Scale total score improved more in the LAI-R group. In contrast, the LAI group had higher Scale for Assessment of Negative Symptoms Alogia scale scores. There were no other between-group differences in symptoms or functional improvement. Despite the advantage for psychotic symptoms, LAI-R did not confer an advantage over oral SGAs for relapse or rehospitalization. Biweekly monitoring, not focusing specifically on patients with demonstrated nonadherence to treatment and greater flexibility in changing medication in the oral treatment arm, may contribute to the inability to detect differences between LAI and oral SGA treatment in clinical trials.

Detecting and Managing Adverse Effects of Antipsychotic Medications: Current State of Play

Antipsychotics are some of the most frequently prescribed medications not only for psychotic disorders and symptoms but also for a wide range of on-label and off-label indications. Because second-generation antipsychotics have largely replaced first-generation antipsychotics as first-line options due to their substantially decreased risk of extrapyramidal side effects, attention has shifted to other clinically concerning adverse events associated with antipsychotic therapy. The focus of this article is to update the nonextrapyramidal side effects associated with second-generation antipsychotics. Issues surrounding diagnosis and monitoring as well as clinical management are addressed.

Behavioral Interventions for Antipsychotic Medication–Associated Obesity: A Randomized, Controlled Clinical Trial

OBJECTIVEnTo demonstrate the effectiveness of a Diabetes Prevention Program-inspired 12-month behavioral intervention for patients with severe mental illness (SMI) and medication-associated obesity.nnnMETHODnThis randomized, controlled, parallel, superiority study screened 225 volunteers from November 2005 to August 2008 at the VA Greater Los Angeles Healthcare System. 122 outpatients with DSM-IV-diagnosed SMI taking antipsychotic medications who had ≥ 7% weight gain or body mass index (BMI) > 25 were randomized by computer-generated number to Lifestyle Balance treatment intervention (n = 60) or usual care control (n = 62) groups. Clinical raters were masked to randomization. Treatment intervention included weekly classes and individual counseling for 8 weeks, food and exercise diaries, rewards, caregiver consultations, and monthly booster classes and counseling for 1 year. Controls received self-help materials and visited at equivalent intervals without formal classes or counseling. Outcomes were changes in anthropometric measurements, psychiatric symptoms, health knowledge, and glucose, hemoglobin A1c, and lipid levels.nnnRESULTSnOur intention-to-treat analysis found significant differences in predicted trajectory of mean weight change between the groups over 12 months (P < .01), with treatment participants expected to lose an average 4.6 kg, while control participants would gain an average 0.6 kg. BMI and body fat percentage followed the same pattern. Both groups demonstrated statistically significant improvements in health knowledge quiz scores over time (P = .006), without significant difference between groups.nnnCONCLUSIONSnTreatment was more effective than usual care control in treating medication-associated obesity, independent of SMI diagnosis, antipsychotic medication, and knowledge gained, suggesting that behavioral interventions are effective in SMI patients.nnnTRIAL REGISTRATIONnClinicalTrials.gov Identifier: NCT00344500.

Dance for Veterans: A complementary health program for veterans with serious mental illness

Background: Dance for Veterans, composed of physical, psychological and social elements, is a new patient-centered and recovery-oriented treatment modality for veterans diagnosed with serious mental illness; that is, chronic and functionally impairing psychoses, traumatic stress disorders, and mood and anxiety disorders. This report outlines the development of Dance for Veterans over the past several years within the VA Greater Los Angeles Healthcare System, including curricular rationale, training model and program evaluation. Methods: Participation was voluntary and required only a mental illness diagnosis. Survey data and qualitative feedback (N = 88), as well as verbal reports of stress (N = 35), were collected over 3-month periods to assess effects of the class on veterans’ well-being. Results: Verbal reports of stress before and after class showed significant decreases (p < 0.001), and subjective responses to the classes were overwhelmingly positive. Significant longer-term trends in stress reduction, however, were not demonstrable. Conclusions: The Dance for Veterans program shows promise as an interdisciplinary resource for veterans diagnosed with serious mental illness. Future program development will include more detailed evaluation of its effects on veterans’ well-being and extension to additional VA venues and populations.

Predicting relapse in schizophrenia: Is BDNF a plausible biological marker?

Understanding the biological processes that underlie why patients relapse is an issue of fundamental importance to the detection and prevention of relapse in schizophrenia. Brain Derived Neurotrophic Factor (BDNF), a facilitator of brain plasticity, is reduced in patients with schizophrenia. In the present study, we examined whether decreases in plasma BDNF levels could be used as a biological predictor of relapse in schizophrenia. A total of 221 patients were prospectively evaluated for relapse over 30months in the Preventing Relapse in Schizophrenia: Oral Antipsychotics Compared to Injectables: eValuating Efficacy (PROACTIVE) study. Serial blood samples were collected at a maximum of 23 time points during the 30-month trial and BDNF levels were measured in plasma samples by ELISA. Receiver Operating Characteristic (ROC) curve analysis indicated that BDNF was not a significant predictor of relapse, hospitalization or exacerbation. Regardless of treatment group (oral second generation antipsychotic vs. long-acting injectable risperidone microspheres), baseline BDNF value did not differ significantly between those who experienced any of the adverse outcomes and those who did not. While contrary to the study hypothesis, these robust results offer little support for the use of plasma BDNF alone as a biomarker to predict relapse in schizophrenia.

All-data approach to assessing financial capability in people with psychiatric disabilities.

The goal of this project was to develop an evidence-based method to assess the ability of disabled persons to manage federal disability payments. This article describes the development of the Financial Incapability Structured Clinical Assessment done Longitudinally (FISCAL) measure of financial capability. The FISCAL was developed by an iterative process of literature review, pilot testing, and expert consultation. Independent assessors used the FISCAL to rate the financial capability of 118 participants (57% female, 58% Caucasian) who received Social Security disability payments, had recently been treated in acute care facilities for psychiatric disorders, and who did not have representative payees or conservators. Altogether, 48% of participants were determined financially incapable by the FISCAL, of whom 60% were incapable because of unmet basic needs, 91% were incapable because of spending that harmed them (e.g., on illicit drugs or alcohol), 56% were incapable because of both unmet needs and harmful spending, and 5% were incapable because of contextual factors. As expected, incapable individuals scored higher on a measure of money mismanagement (p < .001) compared with capable individuals. Interrater reliability for FISCAL capability determinations was very good (κ = .77) and interrater agreement was 89%. In this population, the FISCAL had construct validity; ratings demonstrated good reliability and correlated with a related measure. Potentially, the FISCAL can be used to validate other measures of capability and to help understand how people on limited incomes manage their funds.

Development of the Clinician Assessment of Financial Incapability (CAFI)

The Social Security Administration (SSA) provides financial support to adults disabled by psychiatric conditions to provide for their basic needs. For beneficiaries identified as incapable of managing their funds, representative payee assignment is mandated. However, studies indicate that the current SSA method of determining capability leads to idiosyncratic payee assignment, with a tendency to under-identify beneficiaries needing payees. Over two phases with data from 78 mental health clinicians treating 134 patient-beneficiaries, we describe the development of a new assessment, the Clinician Assessment of Financial Incapability (CAFI). Item generation, subscale construction, and preliminary assessments of validity are described. We also describe the simultaneous development of a criterion measure of capability, a comprehensive review of all data. Experts identified four subscales mapping to four criteria of incapability; factor analysis provided support for this item structure. Close to one-half of patients were determined to be incapable by review of all data. CAFI and SSA methods correctly classified 73% of cases, but errors with CAFI were more evenly distributed between false negatives and false positives. The implications of classification error are considered, and advantages of CAFI over the SSA method are enumerated. Plans for future instrument revision are briefly described.

A Randomized, Controlled Multisite Study of Behavioral Interventions for Veterans with Mental Illness and Antipsychotic Medication-Associated Obesity

BackgroundWeight gain and other metabolic sequelae of antipsychotic medications can lead to medication non-adherence, reduced quality of life, increased costs, and premature mortality. Of the approaches to address this, behavioral interventions are less invasive, cost less, and can result in sustained long-term benefits.ObjectiveWe investigated behavioral weight management interventions for veterans with mental illness across four medical centers within the Veterans Affairs (VA) Healthcare System.DesignWe conducted a 12-month, multi-site extension of our previous randomized, controlled study, comparing treatment and control groups.ParticipantsVeterans (and some non-veteran women) diagnosed with mental illness, overweight (defined as having a BMI over 25), and required ongoing antipsychotic therapy.InterventionsOne group received “Lifestyle Balance” (LB; modified from the Diabetes Prevention Program) consisting of classes and individual nutritional counseling with a dietitian. A second group received less intensive “Usual Care” (UC) consisting of weight monitoring and provision of self-help.Main MeasuresParticipants completed anthropometric and nutrition assessments weekly for 8xa0weeks, then monthly. Psychiatric, behavioral, and physical assessments were conducted at baseline and months 2, 6, and 12. Metabolic and lipid laboratory tests were performed quarterly.Key ResultsParticipants in both groups lost weight. LB participants had a greater decrease in average waist circumference [F(1,1244)u2009=u200911.9, pu2009<u20090.001] and percent body fat [F(1,1121)u2009=u20094.3, pu2009=u20090.038]. Controlling for gender yielded statistically significant changes between groups in BMI [F(1,1246)u2009=u200913.9, pu2009<u20090.001]. Waist circumference and percent body fat decreased for LB women [F(1,1243)u2009=u200922.5, pu2009<u20090.001 and F(1,1221)u2009=u20094.8, pu2009=u20090.029, respectively]. The majority of LB participants kept food and activity journals (92%), and average daily calorie intake decreased from 2055 to 1650 during the study (pu2009<u20090.001).ConclusionsBehavioral interventions specifically designed for individuals with mental illness can be effective for weight loss and improve dietary behaviors. “Lifestyle Balance” integrates well with VA healthcare’s patient-centered “Whole Health” approach.ClinicalTrials.gov identifier NCT01052714.

Poster 253 Efficacy and Safety of a Lifestyle Balance Program for Antipsychotic Medication Associated Obesity

block after being evaluated by 2 independent pain physicians. The patient experienced an excellent result immediately on the procedure table. We will discuss 3 other case scenarios. We will review the medical literature to identify the pain generators after a spinal wedge fracture and evaluate the validity of the entire medical literature about vertebroplasty as a tool for pain management. Discussion: We believe that there has never been mention in the medical literature of thoracic medial branch block compared with the thoracic vertebroplasty for pain management. However, we will provide information about the pain generators in the spinal wedge fracture, and we will explain why we believe that possibly medial branch block would play a tremendous role for pain management in this group of patients.