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Keshaviah A, Huff I, Hu XC, Guidry V, Christensen A, Berkowitz S, Reckling S, Noble RT, Clerkin T, Blackwood D, McLellan SL, Roguet A, Musse I. Separating signal from noise in wastewater data: An algorithm to identify community-level COVID-19 surges in real time. Proc Natl Acad Sci U S A 2023; 120:e2216021120. [PMID: 37490532 PMCID: PMC10401018 DOI: 10.1073/pnas.2216021120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 06/11/2023] [Indexed: 07/27/2023] Open
Abstract
Wastewater monitoring has provided health officials with early warnings for new COVID-19 outbreaks, but to date, no approach has been validated to distinguish signal (sustained surges) from noise (background variability) in wastewater data to alert officials to the need for heightened public health response. We analyzed 62 wk of data from 19 sites participating in the North Carolina Wastewater Monitoring Network to characterize wastewater metrics around the Delta and Omicron surges. We found that wastewater data identified outbreaks 4 to 5 d before case data (reported on the earlier of the symptom start date or test collection date), on average. At most sites, correlations between wastewater and case data were similar regardless of how wastewater concentrations were normalized and whether calculated with county-level or sewershed-level cases, suggesting that officials may not need to geospatially align case data with sewershed boundaries to gain insights into disease transmission. Although wastewater trend lines captured clear differences in the Delta versus Omicron surge trajectories, no single wastewater metric (detectability, percent change, or flow-population normalized viral concentrations) reliably signaled when these surges started. After iteratively examining different combinations of these three metrics, we developed the Covid-SURGE (Signaling Unprecedented Rises in Groupwide Exposure) algorithm, which identifies unprecedented signals in the wastewater data. With a true positive rate of 82%, a false positive rate of 7%, and strong performance during both surges and in small and large sites, our algorithm provides public health officials with an automated way to flag community-level COVID-19 surges in real time.
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Affiliation(s)
| | - Ian Huff
- Mathematica, Inc., Princeton, NJ 08543
| | | | - Virginia Guidry
- North Carolina Department of Health and Human Services, Division of Public Health, Raleigh, NC 27609
| | - Ariel Christensen
- North Carolina Department of Health and Human Services, Division of Public Health, Raleigh, NC 27609
| | - Steven Berkowitz
- North Carolina Department of Health and Human Services, Division of Public Health, Raleigh, NC 27609
| | - Stacie Reckling
- North Carolina Department of Health and Human Services, Division of Public Health, Raleigh, NC 27609
| | - Rachel T Noble
- Institute of Marine Sciences, University of North Carolina-Chapel Hill, Morehead City, NC 28557
| | - Thomas Clerkin
- Institute of Marine Sciences, University of North Carolina-Chapel Hill, Morehead City, NC 28557
| | - Denene Blackwood
- Institute of Marine Sciences, University of North Carolina-Chapel Hill, Morehead City, NC 28557
| | - Sandra L McLellan
- School of Freshwater Sciences, University of Wisconsin-Milwaukee, Milwaukee, WI 53204
| | - Adélaïde Roguet
- School of Freshwater Sciences, University of Wisconsin-Milwaukee, Milwaukee, WI 53204
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Keshaviah A, Diamond MB, Wade MJ, Scarpino SV. Wastewater monitoring can anchor global disease surveillance systems. Lancet Glob Health 2023; 11:e976-e981. [PMID: 37202030 DOI: 10.1016/s2214-109x(23)00170-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/28/2023] [Accepted: 03/27/2023] [Indexed: 05/20/2023]
Abstract
To inform the development of global wastewater monitoring systems, we surveyed programmes in 43 countries. Most programmes monitored predominantly urban populations. In high-income countries (HICs), composite sampling at centralised treatment plants was most common, whereas grab sampling from surface waters, open drains, and pit latrines was more typical in low-income and middle-income countries (LMICs). Almost all programmes analysed samples in-country, with an average processing time of 2·3 days in HICs and 4·5 days in LMICs. Whereas 59% of HICs regularly monitored wastewater for SARS-CoV-2 variants, only 13% of LMICs did so. Most programmes share their wastewater data internally, with partnering organisations, but not publicly. Our findings show the richness of the existing wastewater monitoring ecosystem. With additional leadership, funding, and implementation frameworks, thousands of individual wastewater initiatives can coalesce into an integrated, sustainable network for disease surveillance-one that minimises the risk of overlooking future global health threats.
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Affiliation(s)
| | | | - Matthew J Wade
- Analytics & Data Science Directorate, UK Health Security Agency, London, UK
| | - Samuel V Scarpino
- Institute for Experiential AI, Network Science Institute, Department of Health Sciences, and Khoury College of Computer Sciences, Northeastern University, Boston, MA, USA; Santa Fe Institute, Santa Fe, NM, USA; Vermont Complex Systems Center, University of Vermont, Burlington, VT, USA.
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Lennon RP, Zgierska AE, Miller EL, Snyder B, Keshaviah A, Hu XC, Zhou H, Van Scoy LJ. Lower Intent to Comply with COVID-19 Public Health Recommendations Correlates to Higher Disease Burden in Following 30 Days. South Med J 2021; 114:744-750. [PMID: 34853849 PMCID: PMC8607922 DOI: 10.14423/smj.0000000000001332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2021] [Indexed: 01/12/2023]
Abstract
OBJECTIVES We sought to determine whether self-reported intent to comply with public health recommendations correlates with future coronavirus disease 2019 (COVID-19) disease burden. METHODS A cross-sectional, online survey of US adults, recruited by snowball sampling, from April 9 to July 12, 2020. Primary measurements were participant survey responses about their intent to comply with public health recommendations. Each participant's intent to comply was compared with his or her local COVID-19 case trajectory, measured as the 7-day rolling median percentage change in COVID-19 confirmed cases within participants' 3-digit ZIP code area, using public county-level data, 30 days after participants completed the survey. RESULTS After applying raking techniques, the 10,650-participant sample was representative of US adults with respect to age, sex, race, and ethnicity. Intent to comply varied significantly by state and sex. Lower reported intent to comply was associated with higher COVID-19 case increases during the following 30 days. For every 3% increase in intent to comply with public health recommendations, which could be achieved by improving average compliance by a single point for a single item, we estimate a 9% reduction in new COVID-19 cases during the subsequent 30 days. CONCLUSIONS Self-reported intent to comply with public health recommendations may be used to predict COVID-19 disease burden. Measuring compliance intention offers an inexpensive, readily available method of predicting disease burden that can also identify populations most in need of public health education aimed at behavior change.
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Lennon RP, Fraleigh R, Van Scoy LJ, Keshaviah A, Hu XC, Snyder BL, Miller EL, Calo WA, Zgierska AE, Griffin C. Developing and testing an automated qualitative assistant (AQUA) to support qualitative analysis. Fam Med Community Health 2021; 9:fmch-2021-001287. [PMID: 34824135 PMCID: PMC8627418 DOI: 10.1136/fmch-2021-001287] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Qualitative research remains underused, in part due to the time and cost of annotating qualitative data (coding). Artificial intelligence (AI) has been suggested as a means to reduce those burdens, and has been used in exploratory studies to reduce the burden of coding. However, methods to date use AI analytical techniques that lack transparency, potentially limiting acceptance of results. We developed an automated qualitative assistant (AQUA) using a semiclassical approach, replacing Latent Semantic Indexing/Latent Dirichlet Allocation with a more transparent graph-theoretic topic extraction and clustering method. Applied to a large dataset of free-text survey responses, AQUA generated unsupervised topic categories and circle hierarchical representations of free-text responses, enabling rapid interpretation of data. When tasked with coding a subset of free-text data into user-defined qualitative categories, AQUA demonstrated intercoder reliability in several multicategory combinations with a Cohen’s kappa comparable to human coders (0.62–0.72), enabling researchers to automate coding on those categories for the entire dataset. The aim of this manuscript is to describe pertinent components of best practices of AI/machine learning (ML)-assisted qualitative methods, illustrating how primary care researchers may use AQUA to rapidly and accurately code large text datasets. The contribution of this article is providing guidance that should increase AI/ML transparency and reproducibility.
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Affiliation(s)
- Robert P Lennon
- Family and Community Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Robbie Fraleigh
- Applied Research Laboratory, Pennsylvania State University, University Park, Pennsylvania, USA
| | - Lauren J Van Scoy
- Internal Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | | | - Xindi C Hu
- Mathematica Policy Research Inc, Princeton, New Jersey, USA
| | - Bethany L Snyder
- Center for Community Health Integration, Case Western Reserve University, Cleveland, Ohio, USA
| | - Erin L Miller
- Family and Community Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - William A Calo
- Public Health Services, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aleksandra E Zgierska
- Family and Community Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Christopher Griffin
- Applied Research Laboratory, Pennsylvania State University, University Park, Pennsylvania, USA
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Phillips KA, Greenberg JL, Hoeppner SS, Weingarden H, O’Keefe S, Keshaviah A, Schoenfeld DA, Wilhelm S. Predictors and moderators of symptom change during cognitive-behavioral therapy or supportive psychotherapy for body dysmorphic disorder. J Affect Disord 2021; 287:34-40. [PMID: 33773357 PMCID: PMC8276884 DOI: 10.1016/j.jad.2021.03.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Research on predictors of treatment outcome in body dysmorphic disorder, a common and severe disorder, is very limited, and no prior studies have examined moderators of outcome. Because treatment is often but not always efficacious, it is important to identify who is more likely to benefit. We examined predictors and moderators of improvement with therapist-delivered cognitive-behavioral therapy versus supportive psychotherapy in the only study of these treatments for body dysmorphic disorder. This report presents secondary analyses from a study whose primary findings have previously been published (Wilhelm et al., 2019). METHODS Participants (N=120) with DSM-IV body dysmorphic disorder were randomized to therapist-delivered weekly cognitive-behavioral therapy or supportive therapy for 24 weeks. Using reliable and valid measures, we tested baseline body dysmorphic disorder severity, insight/delusionality, and depression severity as predictors and moderators of overall and treatment modality-specific symptom change. We explored additional variables as predictors and moderators of outcome. RESULTS Greater treatment credibility (p=0.02) and presence of obsessive-compulsive personality disorder (p=0.03) predicted greater improvement. Serotonin-reuptake inhibitor treatment at baseline (unchanged during the study) (p=0.01) predicted less improvement. No other variables predicted or moderated outcome (all p>0.05). LIMITATIONS The study was not powered a priori to detect predictor or moderation effects, which limited our ability to detect them unless they were strong. CONCLUSIONS Because greater treatment credibility predicted better outcomes, fostering credibility during therapy may maximize gains. Improvement was not impeded by more severe body dysmorphic disorder, depressive symptoms, or poorer insight. No variables moderated treatment-specific improvement.
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Affiliation(s)
- Katharine A. Phillips
- Rhode Island Hospital,Alpert Medical School of Brown University,New York-Presbyterian Hospital,Weill Cornell Medical College, Cornell University
| | | | | | | | | | - Aparna Keshaviah
- Massachusetts General Hospital,Harvard Medical School,Mathematica Policy Research
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Keshaviah A, Hu XC, Henry M. Erratum: "Developing a Flexible National Wastewater Surveillance System for COVID-19 and Beyond". Environ Health Perspect 2021; 129:59001. [PMID: 34014765 PMCID: PMC8137097 DOI: 10.1289/ehp9531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 06/12/2023]
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Keshaviah A, Hu XC, Henry M. Developing a Flexible National Wastewater Surveillance System for COVID-19 and Beyond. Environ Health Perspect 2021; 129:45002. [PMID: 33877858 PMCID: PMC8057681 DOI: 10.1289/ehp8572] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 03/04/2021] [Accepted: 03/26/2021] [Indexed: 05/02/2023]
Abstract
BACKGROUND Wastewater testing offers a cost-effective strategy for measuring population disease prevalence and health behaviors. For COVID-19, wastewater surveillance addresses testing gaps and provides an early warning for outbreaks. As U.S. federal agencies build a National Wastewater Surveillance System around the pandemic, thinking through ways to develop flexible frameworks for wastewater sampling, testing, and reporting can avoid unnecessary system overhauls for future infectious disease, chronic disease, and drug epidemics. OBJECTIVES We discuss ways to transform a historically academic exercise into a tool for epidemic response. We generalize lessons learned by a global network of wastewater researchers around validation and implementation for COVID-19 and opioids while also drawing on our experience with wastewater-based epidemiology in the United States. DISCUSSION Sustainable wastewater surveillance requires coordination between health and safety officials, utilities, labs, and researchers. Adapting sampling frequency, type, and location to threat level, community vulnerability, biomarker properties, and decisions that wastewater data will inform can increase the practical value of the data. Marketplace instabilities, coupled with a fragmented testing landscape due to specialization, may require officials to engage multiple labs to test for known and unknown threats. Government funding can stabilize the market, balancing commercial pressures with public good, and incentivize data sharing. When reporting results, standardizing metrics and contextualizing wastewater data with health resource data can provide insights into a community's vulnerability and identify strategies to prevent health care systems from being overwhelmed. If wastewater data will inform policy decisions for an entire community, comparing characteristics of the wastewater treatment plant's service population to those of the larger community can help determine whether the wastewater data are generalizable. Ethical protocols may be needed to protect privacy and avoid stigmatization. With data-driven approaches to sample collection, analysis, and interpretation, officials can use wastewater surveillance for adaptive resource allocation, pandemic management, and program evaluation. https://doi.org/10.1289/EHP8572.
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Fang A, Steketee G, Keshaviah A, Didie E, Phillips KA, Wilhelm S. Mechanisms of Change in Cognitive Behavioral Therapy for Body Dysmorphic Disorder. Cognit Ther Res 2020; 44:596-610. [PMID: 38031584 PMCID: PMC10686577 DOI: 10.1007/s10608-020-10080-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Although cognitive-behavioral therapy (CBT) is highly efficacious for body dysmorphic disorder (BDD), not all patients benefit, and mechanisms underlying response remain unknown. In this first report of the mechanisms underlying improvement with CBT for BDD, we examined whether cognitive (maladaptive beliefs, perfectionism, schemas) and behavioral (checking, grooming, avoidance behaviors) changes mediate the effect of CBT on BDD symptom reduction. Forty-five participants with BDD who enrolled in a CBT for BDD treatment development study were included in two sets of analyses: (1) between-subject mediation of the effect of 12 weeks of CBT versus waitlist, and (2) within-subject mediation of longitudinal change in BDD symptom severity during 24 weeks of CBT. No significant mediators emerged in the between-subject analysis. Checking, grooming, avoidance behaviors, and maladaptive beliefs mediated within-subject improvements over time. Findings suggest that BDD symptom reduction occurs through the very mechanisms that have been hypothesized to maintain BDD in CBT models. Targeting certain cognitive (beliefs about appearance) and behavioral (checking, grooming, and avoidance behaviors) mechanisms in future treatment trials may enhance symptom improvement during CBT. National Clinical Trials Registration Identifier # NCT00106223.
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Affiliation(s)
- Angela Fang
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gail Steketee
- School of Social Work, Boston University, Boston, MA, USA
| | | | - Elizabeth Didie
- Butler Hospital and Alpert Medical School of Brown University, Providence, RI, USA
| | - Katharine A. Phillips
- Butler Hospital and Alpert Medical School of Brown University, Providence, RI, USA
- New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY, USA
| | - Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Simches Research Building, 185 Cambridge Street, Suite 2000, Boston, MA 02114, USA
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Baker A, Simon N, Keshaviah A, Farabaugh A, Deckersbach T, Worthington JJ, Hoge E, Fava M, Pollack MP. Anxiety Symptoms Questionnaire (ASQ): development and validation. Gen Psychiatr 2019; 32:e100144. [PMID: 31922090 PMCID: PMC6936972 DOI: 10.1136/gpsych-2019-100144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 10/23/2019] [Accepted: 11/11/2019] [Indexed: 01/20/2023] Open
Abstract
Background The Anxiety Symptoms Questionnaire (ASQ) is a brief self-report questionnaire which measures frequency and intensity of symptoms and was developed to improve assessment of anxiety symptoms in a clinical setting. We examined the reliability and validity of the ASQ in patients with anxiety disorders and/or depression, non-clinical control subjects and college students. Methods 240 outpatients with generalised anxiety disorder, social anxiety disorder, panic disorder or major depressive disorder were administered the ASQ and additional questionnaires measuring depression and anxiety, as were 111 non-clinical control subjects and 487 college students. Factor analysis, Pearson's correlation coefficients and logistic regression were used to assess reliability and validity. Test-retest reliability of the ASQ was measured using a subset who were re-administered the ASQ after 4 weeks. Results Factor analysis revealed measurement of a single dimension by the ASQ. Internal consistency and test-retest reliability were strong. The ASQ total score also significantly distinguished patients with an anxiety disorder from the clinical controls above and beyond the clinician-rated Hamilton Anxiety Scale. Conclusions The ASQ is a valid, reliable and effective self-rated measure of anxiety and may be a useful tool for screening and assessing anxiety symptoms in psychiatric as well as college settings.
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Affiliation(s)
- Amanda Baker
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Naomi Simon
- New York University Medical Center, New York, New York, USA
| | - Aparna Keshaviah
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Amy Farabaugh
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Thilo Deckersbach
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - John J Worthington
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Elizabeth Hoge
- Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Maurizio Fava
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Wilhelm S, Phillips KA, Greenberg JL, O’Keefe SM, Hoeppner SS, Keshaviah A, Sarvode-Mothi S, Schoenfeld DA. Efficacy and Posttreatment Effects of Therapist-Delivered Cognitive Behavioral Therapy vs Supportive Psychotherapy for Adults With Body Dysmorphic Disorder: A Randomized Clinical Trial. JAMA Psychiatry 2019; 76:363-373. [PMID: 30785624 PMCID: PMC6450292 DOI: 10.1001/jamapsychiatry.2018.4156] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Cognitive behavioral therapy (CBT), the best-studied treatment for body dysmorphic disorder (BDD), has to date not been compared with therapist-delivered supportive psychotherapy, the most commonly received psychosocial treatment for BDD. OBJECTIVE To determine whether CBT for BDD (CBT-BDD) is superior to supportive psychotherapy in reducing BDD symptom severity and associated BDD-related insight, depressive symptoms, functional impairment, and quality of life, and whether these effects are durable. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial conducted at Massachusetts General Hospital and Rhode Island Hospital recruited adults with BDD between October 24, 2011, and July 7, 2016. Participants (n = 120) were randomized to the CBT-BDD arm (n = 61) or the supportive psychotherapy arm (n = 59). Weekly treatments were administered at either hospital for 24 weeks, followed by 3- and 6-month follow-up assessments. Measures were administered by blinded independent raters. Intention-to-treat statistical analyses were performed from February 9, 2017, to September 22, 2018. INTERVENTIONS Cognitive behavioral therapy for BDD, a modular skills-based treatment, addresses the unique symptoms of the disorder. Supportive psychotherapy is a nondirective therapy that emphasizes the therapeutic relationship and self-esteem; supportive psychotherapy was enhanced with BDD-specific psychoeducation and treatment rationale. MAIN OUTCOMES AND MEASURES The primary outcome was BDD symptom severity measured by the change in score on the Yale-Brown Obsessive-Compulsive Scale Modified for BDD from baseline to end of treatment. Secondary outcomes were the associated symptoms and these were assessed using the Brown Assessment of Beliefs Scale, Beck Depression Inventory-Second Edition, Sheehan Disability Scale, and Quality of Life Enjoyment and Satisfaction Questionnaire-Short Form. RESULTS Of the 120 participants, 92 (76.7%) were women, with a mean (SD) age of 34.0 (13.1) years. The difference in effectiveness between CBT-BDD and supportive psychotherapy was site specific: at 1 site, no difference was detected (estimated mean [SE] slopes, -18.6 [1.9] vs -16.7 [1.9]; P = .48; d growth-modeling analysis change, -0.25), whereas at the other site, CBT-BDD led to greater reductions in BDD symptom severity, compared with supportive psychotherapy (estimated mean [SE] slopes, -18.6 [2.2] vs -7.6 [2.0]; P < .001; d growth-modeling analysis change, -1.36). No posttreatment symptom changes were observed throughout the 6 -months of follow-up (all slope P ≥ .10). CONCLUSIONS AND RELEVANCE Body dysmorphic disorder severity and associated symptoms appeared to improve with both CBT-BDD and supportive psychotherapy, although CBT-BDD was associated with more consistent improvement in symptom severity and quality of life. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01453439.
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Affiliation(s)
- Sabine Wilhelm
- Department of Psychiatry, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Katharine A. Phillips
- Department of Psychiatry, Rhode Island Hospital, Providence,Department of Psychiatry, New York-Presbyterian Hospital, New York,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island,Department of Psychiatry, Weill Cornell Medical College, New York, New York
| | - Jennifer L. Greenberg
- Department of Psychiatry, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Sheila M. O’Keefe
- Department of Psychiatry, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Susanne S. Hoeppner
- Department of Psychiatry, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | | | | | - David A. Schoenfeld
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts,Department of Biostatistics, Massachusetts General Hospital, Boston
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11
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Franko DL, Tabri N, Keshaviah A, Murray HB, Herzog DB, Thomas JJ, Coniglio K, Keel PK, Eddy KT. Predictors of long-term recovery in anorexia nervosa and bulimia nervosa: Data from a 22-year longitudinal study. J Psychiatr Res 2018; 96:183-188. [PMID: 29078155 DOI: 10.1016/j.jpsychires.2017.10.008] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/11/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The objective of this study was to investigate predictors of long-term recovery from eating disorders 22 years after entry into a longitudinal study. METHOD One hundred and seventy-six of the 228 surviving participants (77.2%) were re-interviewed 20-25 years after study entry using the Longitudinal Interval Follow-up Evaluation to assess ED recovery. The sample consisted of 100 women diagnosed with anorexia nervosa (AN) and 76 with bulimia nervosa (BN) at study entry. RESULTS A comorbid diagnosis of major depression at the start of the study strongly predicted having a diagnosis of AN-Restricting type at the 22-year assessment. A higher body mass index (BMI) at study intake decreased the odds of being diagnosed with AN-Binge Purge type, relative to being recovered, 22 years later. The only predictor that increased the likelihood of having a diagnosis of BN at the 22-year assessment was the length of time during the study when the diagnostic criteria for BN were met. CONCLUSIONS Together, these results indicate that the presence and persistence of binge eating and purging behaviors were poor prognostic indicators and that comorbidity with depression is particularly pernicious in AN. Treatment providers might pay particular attention to these issues in an effort to positively influence recovery over the long-term.
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Affiliation(s)
- Debra L Franko
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Applied Psychology, Northeastern University, Boston, MA, USA.
| | - Nassim Tabri
- Department of Psychology, Carleton University, Ottawa, Ontario, Canada
| | - Aparna Keshaviah
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Helen B Murray
- Department of Psychology, Drexel University, Philadelphia, PA, USA
| | - David B Herzog
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jennifer J Thomas
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Kathryn Coniglio
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Pamela K Keel
- Department of Psychology, Florida State University, Tallahassee, FL, USA
| | - Kamryn T Eddy
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
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12
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Baker AW, Keshaviah A, Goetter EM, Bui E, Swee M, Rosencrans PL, Simon NM. Examining the Role of Anxiety Sensitivity in Sleep Dysfunction Across Anxiety Disorders. Behav Sleep Med 2017; 15:216-227. [PMID: 26788969 DOI: 10.1080/15402002.2015.1120202] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Anxiety Sensitivity (AS) has been associated with sleep difficulties in certain anxiety disorder populations, but no studies have examined cross-diagnostically the role of anxiety sensitivity in sleep dysfunction. Three hundred one participants with generalized anxiety disorder (GAD), social anxiety disorder (SAD), and panic disorder (PD) completed an ancillary questionnaire-based study. Linear regression was used to examine AS and sleep dysfunction, and mediation analyses were used to examine whether AS was a mediator of the effect of primary diagnosis on sleep. AS was associated with increased sleep dysfunction across anxiety disorders, and primary anxiety disorder diagnosis was significantly associated with sleep dysfunction. However, after controlling for AS, primary diagnosis was no longer significant. AS significantly mediated the effects of PD versus SAD and of PD versus GAD on sleep dysfunction, but did not significantly mediate the effect of GAD versus SAD on sleep dysfunction. Taken together, AS appears to be a more important predictor of sleep dysfunction overall, emphasizing the cross-diagnostic nature of AS and bolstering the RDoC initiative approach for treating psychological dysfunction.
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Affiliation(s)
- Amanda W Baker
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts.,b Harvard Medical School , Boston , Massachusetts
| | - Aparna Keshaviah
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts.,b Harvard Medical School , Boston , Massachusetts
| | - Elizabeth M Goetter
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts.,b Harvard Medical School , Boston , Massachusetts
| | - Eric Bui
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts.,b Harvard Medical School , Boston , Massachusetts
| | - Michaela Swee
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts
| | - Peter L Rosencrans
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts
| | - Naomi M Simon
- a Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts.,b Harvard Medical School , Boston , Massachusetts
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13
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Eddy KT, Tabri N, Thomas JJ, Murray HB, Keshaviah A, Hastings E, Edkins K, Krishna M, Herzog DB, Keel PK, Franko DL. Recovery From Anorexia Nervosa and Bulimia Nervosa at 22-Year Follow-Up. J Clin Psychiatry 2017; 78:184-189. [PMID: 28002660 PMCID: PMC7883487 DOI: 10.4088/jcp.15m10393] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 01/27/2016] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The course of eating disorders is often protracted, with fewer than half of adults achieving recovery from anorexia nervosa or bulimia nervosa. Some argue for palliative management when duration exceeds a decade, yet outcomes beyond 20 years are rarely described. This study investigates early and long-term recovery in the Massachusetts General Hospital Longitudinal Study of Anorexia and Bulimia Nervosa. METHODS Females with DSM-III-R/DSM-IV anorexia nervosa or bulimia nervosa were assessed at 9 and at 20 to 25 years of follow-up (mean [SD] = 22.10 [1.10] years; study initiated in 1987, last follow-up conducted in 2013) via structured clinical interview (Longitudinal Interval Follow-Up Evaluation of Eating Disorders [LIFE-EAT-II]). Seventy-seven percent of the original cohort was re-interviewed, and multiple imputation was used to include all surviving participants from the original cohort (N = 228). Kaplan-Meier curves estimated recovery by 9-year follow-up, and McNemar test examined concordance between recovery at 9-year and 22-year follow-up. RESULTS At 22-year follow-up, 62.8% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa recovered, compared to 31.4% of participants with anorexia nervosa and 68.2% of participants with bulimia nervosa by 9-year follow-up. Approximately half of those with anorexia nervosa who had not recovered by 9 years progressed to recovery at 22 years. Early recovery was associated with increased likelihood of long-term recovery in anorexia nervosa (odds ratio [OR] = 10.5; 95% CI, 3.77-29.28; McNemar χ²₁ = 31.39; P < .01) but not in bulimia nervosa (OR = 1.0; 95% CI, 0.49-2.05; McNemar χ²₁ = 0; P = 1.0). CONCLUSION At 22 years, approximately two-thirds of females with anorexia nervosa and bulimia nervosa were recovered. Recovery from bulimia nervosa happened earlier, but recovery from anorexia nervosa continued over the long term, arguing against the implementation of palliative care for most individuals with eating disorders.
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Affiliation(s)
- Kamryn T. Eddy
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts,Corresponding author: Kamryn T. Eddy, PhD, Eating Disorders Clinical and Research Program, Massachusetts General Hospital, 2 Longfellow Pl, Ste 200, Boston, MA 02114 ()
| | - Nassim Tabri
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Jennifer J. Thomas
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston,Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Helen B. Murray
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston
| | - Aparna Keshaviah
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston
| | - Elizabeth Hastings
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston
| | - Katherine Edkins
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston
| | - Meera Krishna
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston
| | - David B. Herzog
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Pamela K. Keel
- Department of Psychology, Florida State University, Tallahassee
| | - Debra L. Franko
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston,Department of Applied Psychology, Northeastern University, Boston, Massachusetts
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14
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Vollmer L, Keshaviah A, Poznyak D, Zhao S, Xing F, Beyler N. Re-Defining the Who, When, and Where of Mentoring for Professional Statisticians. AM STAT 2017. [DOI: 10.1080/00031305.2016.1255256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
| | | | | | | | - Fei Xing
- Mathematica Policy Research, Washington, DC
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15
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Cassano P, Bui E, Rogers AH, Walton ZE, Ross R, Zeng M, Nadal-Vicens M, Mischoulon D, Baker AW, Keshaviah A, Worthington J, Hoge EA, Alpert J, Fava M, Wong KK, Simon NM. Inflammatory cytokines in major depressive disorder: A case-control study. Aust N Z J Psychiatry 2017; 51:23-31. [PMID: 27313138 PMCID: PMC5731241 DOI: 10.1177/0004867416652736] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION There is mixed evidence in the literature on the role of inflammation in major depressive disorder. Contradictory findings are attributed to lack of rigorous characterization of study subjects, to the presence of concomitant medical illnesses, to the small sample sizes, and to the limited number of cytokines tested. METHODS Subjects aged 18-70 years, diagnosed with major depressive disorder and presenting with chronic course of illness, as well as matched controls ( n = 236), were evaluated by trained raters and provided blood for cytokine measurements. Cytokine levels in EDTA plasma were measured with the MILLIPLEX Multi-Analyte Profiling Human Cytokine/Chemokine Assay employing Luminex technology. The Wilcoxon rank-sum test was used to compare cytokine levels between major depressive disorder subjects and healthy volunteers, before (interleukin [IL]-1β, IL-6, and tumor necrosis factor-α) and after Bonferroni correction for multiple comparisons (IL-1α, IL-2, IL-3, IL-4, IL-5, IL-7, IL-8, IL-10, IL-12(p40), IL-12(p70), IL-13, IL-15, IFN-γ-inducible protein 10, Eotaxin, interferon-γ, monotype chemoattractant protein-1, macrophage inflammatory protein-1α, granulocyte-macrophage colony-stimulating factor and vascular endothelial growth factor). RESULTS There were no significant differences in cytokine levels between major depressive disorder subjects and controls, both prior to and after correction for multiple analyses (significance set at p ⩽ 0.05 and p ⩽ 0.002, respectively). CONCLUSION Our well-characterized examination of cytokine plasma levels did not support the association of major depressive disorder with systemic inflammation. The heterogeneity of major depressive disorder, as well as a potential sampling bias selecting for non-inflammatory depression, might have determined our findings discordant with the literature.
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Affiliation(s)
- Paolo Cassano
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Bui
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew H Rogers
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | | | - Rachel Ross
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Mary Zeng
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Mireya Nadal-Vicens
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - David Mischoulon
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Amanda W Baker
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Aparna Keshaviah
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - John Worthington
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth A Hoge
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jonathan Alpert
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Maurizio Fava
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Kwok K Wong
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Naomi M Simon
- Center for Anxiety and Traumatic Stress Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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16
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Phillips KA, Keshaviah A, Dougherty D, Stout RL, Menard W, Wilhelm S. Pharmacotherapy Relapse Prevention in Body Dysmorphic Disorder: A Double-Blind, Placebo-Controlled Trial. Am J Psychiatry 2016; 173:887-95. [PMID: 27056606 PMCID: PMC5009005 DOI: 10.1176/appi.ajp.2016.15091243] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Body dysmorphic disorder is common, distressing, and often severely impairing. Serotonin reuptake inhibitors appear efficacious, but the few existing pharmacotherapy studies were short term (≤4 months), and no relapse prevention studies or continuation phase studies have been conducted to the authors' knowledge. The authors report results from the first relapse prevention study in body dysmorphic disorder. METHOD Adults (N=100) with DSM-IV body dysmorphic disorder received open-label escitalopram for 14 weeks (phase 1); 58 responders were then randomized to double-blind continuation treatment with escitalopram versus switch to placebo for 6 months (phase 2). Reliable and valid outcome measures were utilized. RESULTS In phase 1, 67.0% of treated subjects and 81.1% of subjects who completed phase 1 responded to escitalopram. Body dysmorphic disorder severity (in both the intent-to-treat and the completer groups) and insight, depressive symptoms, psychosocial functioning, and quality of life significantly improved from baseline to end of phase 1. In phase 2, time to relapse was significantly longer with escitalopram than with placebo treatment (hazard ratio=2.72, 95% CI=1.01-8.57). Phase 2 relapse proportions were 18% for escitalopram and 40% for placebo. Among escitalopram-treated subjects, body dysmorphic disorder severity significantly decreased over time during the continuation phase, with 35.7% of subjects showing further improvement. There were no significant group differences in body dysmorphic disorder severity or insight, depressive symptoms, psychosocial functioning, or quality of life. CONCLUSIONS Continuation-phase escitalopram delayed time to relapse, and fewer escitalopram-treated subjects relapsed than did placebo-treated subjects. Body dysmorphic disorder severity significantly improved during 6 additional months of escitalopram treatment following acute response; more than one-third of escitalopram-treated subjects experienced further improvement.
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Affiliation(s)
- Katharine A. Phillips
- Rhode Island Hospital and Butler Hospital, Providence, RI,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI
| | | | - Darin Dougherty
- Massachusetts General Hospital, Boston MA,Department of Psychiatry, Harvard Medical School, Boston MA
| | - Robert L. Stout
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI,Decision Sciences Institute, Pawtucket, RI
| | - William Menard
- Rhode Island Hospital and Butler Hospital, Providence, RI
| | - Sabine Wilhelm
- Massachusetts General Hospital, Boston MA,Department of Psychiatry, Harvard Medical School, Boston MA
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17
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Baker AW, Keshaviah A, Horenstein A, Goetter EM, Mauro C, Reynolds C, Zisook S, Shear MK, Simon NM. The role of avoidance in complicated grief: A detailed examination of the Grief-Related Avoidance Questionnaire (GRAQ) in a large sample of individuals with complicated grief. J Loss Trauma 2016; 21:533-547. [PMID: 28649184 PMCID: PMC5482544 DOI: 10.1080/15325024.2016.1157412] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Hofmann SG, Curtiss J, Khalsa SBS, Hoge E, Rosenfield D, Bui E, Keshaviah A, Simon N. Yoga for generalized anxiety disorder: design of a randomized controlled clinical trial. Contemp Clin Trials 2015; 44:70-76. [PMID: 26255236 PMCID: PMC4744580 DOI: 10.1016/j.cct.2015.08.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/31/2015] [Accepted: 08/03/2015] [Indexed: 10/23/2022]
Abstract
Generalized anxiety disorder (GAD) is a common disorder associated with significant distress and interference. Although cognitive behavioral therapy (CBT) has been shown to be the most effective form of psychotherapy, few patients receive or have access to this intervention. Yoga therapy offers another promising, yet under-researched, intervention that is gaining increasing popularity in the general public, as an anxiety reduction intervention. The purpose of this innovative clinical trial protocol is to investigate the efficacy of a Kundalini Yoga intervention, relative to CBT and a control condition. Kundalini yoga and CBT are compared with each other in a noninferiority test and both treatments are compared to stress education training, an attention control intervention, in superiority tests. The sample will consist of 230 individuals with a primary DSM-5 diagnosis of GAD. This randomized controlled trial will compare yoga (N=95) to both CBT for GAD (N=95) and stress education (N=40), a commonly used control condition. All three treatments will be administered by two instructors in a group format over 12 weekly sessions with four to six patients per group. Groups will be randomized using permuted block randomization, which will be stratified by site. Treatment outcome will be evaluated bi-weekly and at 6month follow-up. Furthermore, potential mediators of treatment outcome will be investigated. Given the individual and economic burden associated with GAD, identifying accessible alternative behavioral treatments will have substantive public health implications.
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Affiliation(s)
| | | | - Sat Bir S Khalsa
- Brigham and Women's Hospital, Harvard Medical School, United States
| | | | | | - Eric Bui
- Massachusetts General Hospital, United States
| | | | - Naomi Simon
- Massachusetts General Hospital, United States
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19
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Simon NM, Walton ZE, Bui E, Prescott J, Hoge E, Keshaviah A, Schwarz N, Dryman T, Ojserkis RA, Kovachy B, Mischoulon D, Worthington J, DeVivo I, Fava M, Wong KK. Telomere length and telomerase in a well-characterized sample of individuals with major depressive disorder compared to controls. Psychoneuroendocrinology 2015; 58:9-22. [PMID: 25932992 PMCID: PMC4461511 DOI: 10.1016/j.psyneuen.2015.04.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 04/03/2015] [Accepted: 04/04/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Leukocyte telomere length (LTL) is a marker of cellular turnover and oxidative stress. Studies suggest major depressive disorder (MDD) is associated with oxidative stress, but examinations of MDD and LTL have yielded mixed results, likely because of differences in measurement methods and unmeasured confounding. This study examined LTL and telomerase activity in 166 individuals with MDD compared to 166 age- and gender-matched matched controls free of any psychiatric disorder, using well-validated assays and clinical assessment methods, and controlling for a range of potential confounders. METHODS Subjects aged 18 to 70 were evaluated by trained raters and provided blood for LTL and telomerase activity measurement. LTL was assayed using Southern blot and replicated with qPCR, and telomerase activity was assayed with a repeat amplification protocol using a commercial kit. RESULTS There was no significant difference in telomere length for individuals with MDD [mean (SD)=9.1 (3.0)kbp] compared to controls [mean(SD)=8.9(2.5)kbp] measured by Southern blot (p=0.65) or by confirmatory qPCR (p=0.91) assays. Controlling for potential confounders did not alter the results. Telomerase activity did not differ by MDD diagnosis overall (p=0.40), but the effect of MDD was significantly modified by gender (t(299)=2.67, p=0.0079) even after controlling for potential confounders, with telomerase activity significantly greater only in males with MDD versus controls. CONCLUSION Our well-characterized, well-powered examination of concurrently assessed telomere length and telomerase activity in individuals with clinically significant, chronic MDD and matched controls failed to provide strong evidence of an association of MDD with shorter LTL, while telomerase activity was higher in men with MDD [corrected].
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Affiliation(s)
- Naomi M. Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | | | - Eric Bui
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - Jennifer Prescott
- Program in Genetic Epidemiology and Statistical Genetics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, United States,Dana-Farber Cancer Institute, Boston, MA, United States
| | - Elizabeth Hoge
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - Aparna Keshaviah
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Noah Schwarz
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Taylor Dryman
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Rebecca A. Ojserkis
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - Benjamin Kovachy
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States
| | - David Mischoulon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - John Worthington
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - Immaculata DeVivo
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States,Program in Genetic Epidemiology and Statistical Genetics, Department of Epidemiology, Harvard School of Public Health, Boston, MA, United States
| | - Maurizio Fava
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, United States,Harvard Medical School, Boston, MA, United States
| | - Kwok-Kin Wong
- Harvard Medical School, Boston, MA, United States,Dana-Farber Cancer Institute, Boston, MA, United States
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20
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Wilhelm S, Berman NC, Keshaviah A, Schwartz RA, Steketee G. Mechanisms of change in cognitive therapy for obsessive compulsive disorder: role of maladaptive beliefs and schemas. Behav Res Ther 2014; 65:5-10. [PMID: 25544403 DOI: 10.1016/j.brat.2014.12.006] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Revised: 11/12/2014] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
Abstract
The present study aimed to identify mechanisms of change in individuals with moderately severe obsessive-compulsive disorder (OCD) receiving cognitive therapy (CT). Thirty-six adults with OCD received CT over 24 weeks. At weeks 0, 4/6, 12, 16/18, and 24, independent evaluators assessed OCD severity, along with obsessive beliefs and maladaptive schemas. To examine mechanisms of change, we utilized a time-varying lagged regression model with a random intercept and slope. Results indicated that perfectionism and certainty obsessive beliefs and maladaptive schemas related to dependency and incompetence significantly mediated (improved) treatment response. In conclusion, cognitive changes in perfectionism/certainty beliefs and maladaptive schemas related to dependency/incompetence precede behavioral symptom reduction for OCD patients. Targeting these mechanisms in future OCD treatment trials will emphasize the most relevant processes and facilitate maximum improvement.
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Affiliation(s)
- Sabine Wilhelm
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, 185 Cambridge Street, Suite 2000, Boston, MA 0214, United States.
| | - Noah C Berman
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, 185 Cambridge Street, Suite 2000, Boston, MA 0214, United States
| | - Aparna Keshaviah
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, 185 Cambridge Street, Suite 2000, Boston, MA 0214, United States
| | - Rachel A Schwartz
- Massachusetts General Hospital, Harvard Medical School, Department of Psychiatry, 185 Cambridge Street, Suite 2000, Boston, MA 0214, United States
| | - Gail Steketee
- Boston University School of Social Work, 264Bay State Rd., Boston, MA 02215, United States
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21
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Keshaviah A, Edkins K, Hastings ER, Krishna M, Franko DL, Herzog DB, Thomas JJ, Murray HB, Eddy KT. Re-examining premature mortality in anorexia nervosa: a meta-analysis redux. Compr Psychiatry 2014; 55:1773-84. [PMID: 25214371 DOI: 10.1016/j.comppsych.2014.07.017] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 10/25/2022] Open
Abstract
Anorexia nervosa (AN) is reported to have the highest premature mortality of any psychiatric disorder, but recent meta-analyses may have inflated estimates. We sought to re-estimate mortality after methodological corrections and to identify predictors of mortality. We included 41 cohorts from 40 peer-reviewed studies published between 1966 and 2010. Methods included double data extraction, log-linear regression with an over-dispersed Poisson model, and all-cause and suicide-specific standardized mortality ratios (SMRs), with 95% Poisson confidence intervals. Participants with AN were 5.2 [3.7-7.5] times more likely to die prematurely from any cause, and 18.1 [11.5-28.7] times more likely to die by suicide than 15-34 year old females in the general population. Our estimates were 10% and 49% lower, respectively, than previously reported SMRs. Risk of premature mortality was highest in studies with older participants, although confounding by treatment was present. Gender, ascertainment, and diagnostic criteria also impacted risk.
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Affiliation(s)
- Aparna Keshaviah
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Katherine Edkins
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Elizabeth R Hastings
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; The Amundsen Group, Burlington, MA, USA
| | - Meera Krishna
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Debra L Franko
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Northeastern University, Boston, MA, USA
| | - David B Herzog
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Jennifer J Thomas
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Helen B Murray
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA
| | - Kamryn T Eddy
- Eating Disorders Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA; Department of Psychiatry, Harvard Medical School, Boston, MA, USA.
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22
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Wilhelm S, Phillips KA, Didie E, Buhlmann U, Greenberg JL, Fama JM, Keshaviah A, Steketee G. Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behav Ther 2014; 45:314-27. [PMID: 24680228 PMCID: PMC4283214 DOI: 10.1016/j.beth.2013.12.007] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 11/13/2013] [Accepted: 12/20/2013] [Indexed: 11/17/2022]
Abstract
There are few effective treatments for body dysmorphic disorder (BDD) and a pressing need to develop such treatments. We examined the feasibility, acceptability, and efficacy of a manualized modular cognitive-behavioral therapy for BDD (CBT-BDD). CBT-BDD utilizes core elements relevant to all BDD patients (e.g., exposure, response prevention, perceptual retraining) and optional modules to address specific symptoms (e.g., surgery seeking). Thirty-six adults with BDD were randomized to 22 sessions of immediate individual CBT-BDD over 24 weeks (n=17) or to a 12-week waitlist (n=19). The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS), Brown Assessment of Beliefs Scale, and Beck Depression Inventory-II were completed pretreatment, monthly, posttreatment, and at 3- and 6-month follow-up. The Sheehan Disability Scale and Client Satisfaction Inventory (CSI) were also administered. Response to treatment was defined as ≥30% reduction in BDD-YBOCS total from baseline. By week 12, 50% of participants receiving immediate CBT-BDD achieved response versus 12% of waitlisted participants (p=0.026). By posttreatment, 81% of all participants (immediate CBT-BDD plus waitlisted patients subsequently treated with CBT-BDD) met responder criteria. While no significant group differences in BDD symptom reduction emerged by Week 12, by posttreatment CBT-BDD resulted in significant decreases in BDD-YBOCS total over time (d=2.1, p<0.0001), with gains maintained during follow-up. Depression, insight, and disability also significantly improved. Patient satisfaction was high, with a mean CSI score of 87.3% (SD=12.8%) at posttreatment. CBT-BDD appears to be a feasible, acceptable, and efficacious treatment that warrants more rigorous investigation.
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Affiliation(s)
- Sabine Wilhelm
- Massachusetts General Hospital and Harvard Medical School.
| | - Katharine A. Phillips
- Rhode Island Hospital and the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
| | - Elizabeth Didie
- Rhode Island Hospital and the Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University
| | - Ulrike Buhlmann
- Institute of Psychology, Humboldt-Universität zu Berlin, Germany
| | | | - Jeanne M. Fama
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School
| | - Aparna Keshaviah
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School
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23
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Stein MB, Keshaviah A, Haddad SA, Van Ameringen M, Simon NM, Pollack MH, Smoller JW. Influence of RGS2 on sertraline treatment for social anxiety disorder. Neuropsychopharmacology 2014; 39:1340-6. [PMID: 24154666 PMCID: PMC3988537 DOI: 10.1038/npp.2013.301] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/15/2013] [Accepted: 10/01/2013] [Indexed: 11/09/2022]
Abstract
Only a minority of patients with social anxiety disorder (SAD) has a robust therapeutic response to evidence-based serotonin reuptake inhibitor (SSRI) treatment. To help improve the personalized medicine approach to psychiatric care, we evaluated several candidate genetic predictors of SSRI response in SAD. At the start of a randomized controlled trial (NCT00282828), 346 patients with SAD at three sites received protocol-driven, open-label treatment with sertraline, up to 200. mg/d over 10 weeks. Efficacy was determined using a continuous measure of outcome (Liebowitz Social Anxiety Scale (LSAS)) and dichotomous indicators of response (LSAS ≤ 50) and remission (LSAS ≤ 30). Predictors of efficacy were examined in multivariate regression models that included eight polymorphic variants in four candidate genes (four in RGS2, two in HTR2A, one in SLC6A2, and one in SLC6A4). Adjusting for genetic ancestral cluster and non-genetic predictors of response, all four single-nucleotide polymorphisms (SNPs) in RGS2 predicted change in LSAS over time, at study-wise significance (p=0.00833), with the minor allele associated with less improvement over time. After adjusting for genetic ancestral cluster and non-genetic predictors of remission, two of the four RGS2 SNPs predicted likelihood of remission at or just below study-wise significance (p=0.025): rs4606 (AOR=0.49 (95% CI=0.27-0.90), p=0.022) and rs1819741 (AOR=0.50 (95% CI=0.28-0.92), p=0.027). Variation in RGS2, a gene previously shown to be associated with social anxiety phenotypes and serotonergic neurotransmission, may be a biomarker of the likelihood of substantially benefiting from sertraline among patients with SAD.
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Affiliation(s)
- Murray B Stein
- Department of Psychiatry and Family and Preventive Medicine, University of California, San Diego, La Jolla, CA, USA,Department of Psychiatry and Family and Preventive Medicine, Anxiety and Traumatic Stress Disorders, University of California, San Diego (Mailcode 0855), 9500 Gilman Drive, La Jolla, CA 92093-0855, USA, Tel: +858 534 6400, Fax: +858 534 6460,
| | - Aparna Keshaviah
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Stephen A Haddad
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Michael Van Ameringen
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, ON, Canada
| | - Naomi M Simon
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Mark H Pollack
- Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA
| | - Jordan W Smoller
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
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Pollack MH, Van Ameringen M, Simon NM, Worthington JW, Hoge EA, Keshaviah A, Stein MB. A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder. Am J Psychiatry 2014; 171:44-53. [PMID: 24399428 DOI: 10.1176/appi.ajp.2013.12101353] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Most patients remain symptomatic after an initial intervention with approved treatments for generalized social anxiety disorder. This randomized controlled trial provides systematic, prospectively derived data on the relative benefits of "next-step" pharmacotherapies to improve outcomes for individuals with generalized social anxiety disorder who remain symptomatic after initial treatment. METHOD This three site, 12-week, double-blind randomized controlled trial compared the relative benefits of three strategies for patients remaining symptomatic (Liebowitz Social Anxiety Scale [LSAS] score >50) after a 10-week trial of sertraline alone: the addition of up to 3.0 mg/day of clonazepam (sertraline plus clonazepam), a switch to up to 225 mg/day of venlafaxine, or prolonged sertraline treatment with placebo (sertraline plus placebo). RESULTS A total of 397 participants received at least one dose of sertraline; 181 nonresponders (LSAS score >50) at week 10 were randomly assigned to sertraline plus clonazepam, switch to venlafaxine, or sertraline plus placebo. Overall, 21% of patients achieved remission (LSAS score ≤30) at the endpoint, and 27% of patients assigned to sertraline plus clonazepam achieved remission compared with patients assigned to sertraline plus placebo (17%) or venlafaxine (19%), but the differences did not reach significance. Sertraline plus clonazepam was associated with a significantly greater drop in LSAS severity (p=0.020) and disability (p=0.0028) compared with sertraline plus placebo; no significant differences were observed on these parameters between venlafaxine and either sertraline plus placebo or sertraline plus clonazepam. In supplemental analysis, the overall response rate (LSAS score ≤50) was 46%, including a significantly greater proportion of patients in the sertraline plus clonazepam group (56%) compared with the sertraline plus placebo group responding (36%; p=0.027); differences did not reach significance between venlafaxine and sertraline plus placebo or sertraline plus clonazepam. CONCLUSIONS The findings suggest that the clonazepam augmentation strategy provides relative benefits for sertraline nonresponders in social anxiety disorder.
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Shingleton RM, Eddy KT, Keshaviah A, Franko DL, Swanson SA, Yu JS, Krishna M, Nock MK, Herzog DB. Binge/purge thoughts in nonsuicidal self-injurious adolescents: an ecological momentary analysis. Int J Eat Disord 2013; 46:684-9. [PMID: 23729243 PMCID: PMC3878293 DOI: 10.1002/eat.22142] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Revised: 04/09/2013] [Accepted: 04/21/2013] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Adolescents who self-injure often engage in bingeing/purging (BP). Ecological momentary assessment (EMA) has potential to offer insight into the relationship between self-injury and BP. The aims of this study were to examine the frequency and context of BP using EMA in a sample of nonsuicidal self-injurious (NSSI) adolescents. METHOD Thirty adolescents with a history of NSSI responded to questions regarding self-destructive thoughts/behaviors using a palm-pilot device. Descriptive analyses compared thought/behavior contexts during reports of BP and NSSI thoughts/behaviors (occurring together vs. individually). RESULTS BP thoughts were present in 22 (73%) participants, occurring on 32% of the person-days recorded; 59% of these participants actually engaged in BP behavior. Seventy-nine percent of BP thoughts co-occurred with other self-destructive thoughts. Adolescents were more often with friends/peers than alone or with family when having BP thoughts. Worry and pressure precipitated both BP and NSSI thoughts, but perceived criticism and feelings of rejection/hurt were associated more often with BP thoughts than with NSSI thoughts. DISCUSSION BP thoughts and behaviors were common in this sample, often occurring with other self-destructive thoughts. Future EMA research is needed to address the function of BP symptoms, the contextual variables that increase risk for BP thoughts, and the factors that predict the transition of thoughts into behaviors in adolescents with and without self-injury.
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Affiliation(s)
| | - Kamryn T. Eddy
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Aparna Keshaviah
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Debra L. Franko
- Department of Counseling and Applied Educational Psychology, Northeastern University, Boston, Massachusetts
| | | | - Jessica S. Yu
- Department of Psychology, Rutgers University, Newark, New Jersey
| | - Meera Krishna
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Matthew K. Nock
- Department of Psychology, Harvard University, Cambridge, Massachusetts
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Bui E, Orr SP, Jacoby RJ, Keshaviah A, LeBlanc NJ, Milad MR, Pollack MH, Simon NM. Two weeks of pretreatment with escitalopram facilitates extinction learning in healthy individuals. Hum Psychopharmacol 2013; 28:447-56. [PMID: 23776033 DOI: 10.1002/hup.2330] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Accepted: 05/02/2013] [Indexed: 01/19/2023]
Abstract
OBJECTIVE We aimed to examine whether pretreatment with escitalopram would be associated with reduced fear acquisition and enhanced extinction learning in a fear conditioning paradigm, compared with placebo. METHODS Healthy volunteers were randomized in double-blind fashion, to 14 days of escitalopram 10 mg/day (n = 18) or placebo (n = 20) prior to a classical fear conditioning paradigm. RESULTS Although escitalopram was associated with a smaller skin conductance (SC) orienting response during habituation, no medication effects on fear acquisition were found. Escitalopram was associated with faster extinction of SC responses, compared with placebo, as revealed by a significant drug × conditioned stimulus × trial interaction for early extinction (F(3, 30) = 3.26, p = 0.035) and late extinction (F(3, 30) = 3.27, p = 0.035) trials. After adjustment for age, orienting response, and acquisition, results from linear contrast remained significant for early extinction (F(1, 29) = 5.43, p = 0.027). CONCLUSIONS Escitalopram administered for 14 days prior to a fear conditioning paradigm did not influence acquisition of a conditioned fear response but did facilitate extinction learning. Impairments in extinction learning have been identified as a key component of posttraumatic stress disorder; our preliminary findings suggest that additional experimental and clinical studies assessing the efficacy of selective serotonin reuptake inhibitors for posttraumatic stress disorder prevention are warranted.
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Affiliation(s)
- Eric Bui
- Center for Anxiety and Traumatic Stress Disorders, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Laboratoire du Stress Traumatique (EA4560), CHU de Toulouse & Université Toulouse 3, Toulouse, France
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Abstract
OBJECTIVE Although anorexia nervosa has a high mortality rate, our understanding of the timing and predictors of mortality in eating disorders is limited. The authors investigated mortality in a long-term study of patients with eating disorders. METHOD Beginning in 1987, 246 treatment-seeking female patients with anorexia nervosa or bulimia nervosa were interviewed every 6 months for a median of 9.5 years to obtain weekly ratings of eating disorder symptoms, comorbidity, treatment participation, and psychosocial functioning. From January 2007 to December 2010 (median follow-up of 20 years), vital status was ascertained with a National Death Index search. RESULTS Sixteen deaths (6.5%) were recorded (lifetime anorexia nervosa, N=14; bulimia nervosa with no history of anorexia nervosa, N=2). The standardized mortality ratio was 4.37 (95% CI=2.4-7.3) for lifetime anorexia nervosa and 2.33 (95% CI=0.3-8.4) for bulimia nervosa with no history of anorexia nervosa. Risk of premature death among patients with lifetime anorexia nervosa peaked within the first 10 years of follow-up, resulting in a standardized mortality ratio of 7.7 (95% CI=3.7-14.2). The standardized mortality ratio varied by duration of illness and was 3.2 (95% CI=0.9-8.3) for patients with lifetime anorexia nervosa for 0 to 15 years (4/119 died), and 6.6 (95% CI=3.2-12.1) for those with lifetime anorexia nervosa for >15 to 30 years (10/67 died). Multivariate predictors of mortality included alcohol abuse, low body mass index, and poor social adjustment. CONCLUSIONS These findings highlight the need for early identification and intervention and suggest that a long duration of illness, substance abuse, low weight, and poor psychosocial functioning raise the risk for mortality in anorexia nervosa.
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Milad MR, Furtak SC, Greenberg JL, Keshaviah A, Im JJ, Falkenstein MJ, Jenike M, Rauch SL, Wilhelm S. Deficits in conditioned fear extinction in obsessive-compulsive disorder and neurobiological changes in the fear circuit. JAMA Psychiatry 2013; 70:608-18; quiz 554. [PMID: 23740049 DOI: 10.1001/jamapsychiatry.2013.914] [Citation(s) in RCA: 232] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Obsessive-compulsive disorder (OCD) may be characterized by impaired self-regulation and behavioral inhibition. Elevated fear and anxiety are common characteristics of this disorder. The neurobiology of fear regulation and consolidation of safety memories have not been examined in this patient population. OBJECTIVE To examine the psychophysiological and neurobiological correlates of conditioned fear extinction in patients with OCD. DESIGN Cross-sectional, case-control, functional magnetic resonance imaging study. SETTING Academic medical center. PARTICIPANTS Twenty-one patients with OCD and 21 healthy participants. MAIN OUTCOMES AND MEASURES Skin conductance responses and blood oxygenation level-dependent responses. RESULTS The between-group difference noted in our psychophysiological measure (skin conductance responses) was during extinction recall: patients with OCD showed impaired extinction recall relative to control subjects. Regarding the functional magnetic resonance imaging data, patients with OCD showed significantly reduced activation in the ventromedial prefrontal cortex across training phases. Moreover, reduced activation in the patients with OCD was noted in the caudate and hippocampus during fear conditioning, as well as in the cerebellum, posterior cingulate cortex, and putamen during extinction recall. Contrary to our prediction, OCD symptom severity was positively correlated with the magnitude of extinction memory recall. Also contrary to our prediction, functional responses of the ventromedial prefrontal cortex were positively correlated with symptom severity, and functional responses of the dorsal anterior cingulate cortex were inversely correlated with symptom severity. CONCLUSIONS AND RELEVANCE As expected, our study showed that fear extinction and its neural substrates are impaired in patients with OCD. However, this study also yielded some surprising and unexpected results regarding the correlates between extinction capacity and its neural substrates and the severity of symptoms expressed in this disorder. Thus, our data report neural correlates of deficient fear extinction in patients with OCD. The negative correlations between fear extinction deficits and Yale-Brown Obsessive-Compulsive Scale symptoms in OCD suggest that there may be other factors, in addition to fear extinction deficiency, that contribute to the psychopathology of OCD.
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Affiliation(s)
- Mohammed R Milad
- Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Charlestown 02129, USA.
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Hoge EA, Lawson EA, Metcalf CA, Keshaviah A, Zak PJ, Pollack MH, Simon NM. Plasma oxytocin immunoreactive products and response to trust in patients with social anxiety disorder. Depress Anxiety 2012; 29:924-30. [PMID: 22807189 PMCID: PMC3751166 DOI: 10.1002/da.21973] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2012] [Revised: 05/11/2012] [Accepted: 06/02/2012] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Generalized Social Anxiety Disorder (GSAD) is characterized by excessive fear and avoidance of several types of social and performance situations. The pathophysiology is not well understood, but research in animals and humans has provided evidence that oxytocin helps regulate normal social affiliative behavior. Previous work in healthy male subjects demonstrated a rise in plasma oxytocin after receiving a high trust signal. To examine the oxytocin system in GSAD, we measured plasma oxytocin in GSAD patients and controls, before and after the social "Trust Game," a neuroeconomic test examining trust behavior and reaction to trust using real monetary incentives. METHODS Thirty-nine subjects with GSAD and 28 healthy controls provided three blood samples for oxytocin measurement before the Trust Game, and one sample after the game. Plasma estradiol was also measured at baseline. The Trust Game protocol version prioritized the sending of a signal of high cooperation and trust to all participants. All analyses controlled for gender and estradiol levels. RESULTS Mean oxytocin levels post-Trust Game (P = .025), and overall (area under the curve, P = .011) were lower in GSADpatients compared to controls, after controlling for sex and estradiol. There was no significant change in oxytocin levels after the game in either group. CONCLUSIONS We report low plasma oxytocin levels in patients with GSAD during a prosocial laboratory task paradigm. Additional research will be important to further examine the relationship between oxytocin and social behavior in GSAD.
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Affiliation(s)
- EA Hoge
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - EA Lawson
- Neuroendocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - CA Metcalf
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - A Keshaviah
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - PJ Zak
- Center for Neuroeconomics Studies, Claremont Graduate University, Claremont, CA
| | - MH Pollack
- Department of Psychiatry, Rush University Medical Center, Chicago, IL
| | - NM Simon
- Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA
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Marques L, Porter E, Keshaviah A, Pollack MH, Van Ameringen M, Stein MB, Simon NM. Avoidant personality disorder in individuals with generalized social anxiety disorder: what does it add? J Anxiety Disord 2012; 26:665-72. [PMID: 22705954 PMCID: PMC3417304 DOI: 10.1016/j.janxdis.2012.05.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 05/14/2012] [Accepted: 05/19/2012] [Indexed: 11/18/2022]
Abstract
Avoidant personality disorder (AvPD) has a high level of symptom overlap and comorbidity with generalized social anxiety disorder (GSAD). We examined whether the presence of comorbid AvPD adds significant clinically relevant information for individuals seeking treatment for GSAD. Results suggested that AvPD was significantly associated with poorer quality of life and greater disability in univariate, but not multivariate analyses. Endorsement of more AvPD symptoms was associated with increased disability, increased risk of intimacy, and lower social support, even after covariate adjustment. Specifically, AvPD item 3, hard to be "open" even with people you are close to, was most strongly correlated with quality of life and disability. A binary diagnosis of AvPD alone adds little beyond a marker of greater GSAD severity and depression among patients with GSAD, while a specific feature of AvPD not captured by the GSAD diagnosis, namely emotional guardedness, may be associated with greater impairment.
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Affiliation(s)
- Luana Marques
- Department of Psychiatry, Massachusetts General Hospital, 1 Bowdoin Square, 6th Floor, Boston, MA 02114-2790, United States.
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Marques L, LeBlanc N, Robinaugh D, Weingarden H, Keshaviah A, Wilhelm S. Correlates of quality of life and functional disability in individuals with body dysmorphic disorder. Psychosomatics 2011; 52:245-54. [PMID: 21565596 DOI: 10.1016/j.psym.2010.12.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Revised: 07/23/2010] [Accepted: 07/26/2010] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Body dysmorphic disorder (BDD) is a chronic mental illness characterized by low quality of life and functional disability across multiple domains. Despite the clinical importance of understanding impairment in BDD, there has been little research examining the factors that contribute to these constructs. The present study was designed to examine sociodemographic and clinical correlates of quality of life and disability (work, social, and family) in a sample of individuals with moderately severe BDD symptoms. METHOD Participants completed an internet survey with questions about demographics, BDD phenomenology, treatment, and impairment. Only participants who completed all study measures and received a score≥16 on the 10-item Yale-Brown Obsessive Compulsive Scale, Modified for BDD (BDD-YBOCS), indicating the presence of clinical BDD symptoms, were included in the analysis (n=256). Multivariate regression with backwards variable selection was used to identify significant predictors of quality of life and functional disability, assessed with the Quality of Life Enjoyment and Satisfaction Scale-Short Form (QLESQ-SF) and the Sheehan Disability Scale (SDS), respectively. RESULTS BDD symptom severity was inversely associated with quality of life and directly associated with disability in all domains. After controlling statistically for BDD symptom severity, sociodemographic and clinical factors such as age, gender, ethnicity, marital status, insurance, body parts of concern, depression symptoms, and anxiety symptoms were significantly associated with impairment. CONCLUSION Results suggest a multidimensional nature of quality of life and functional disability and underscore the importance of developing holistic treatment strategies to address impairment in BDD.
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Affiliation(s)
- Luana Marques
- Massachusetts General Hospital Department of Psychiatry and Harvard Medical School, Boston, MA 02114, USA.
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32
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Timpano KR, Exner C, Glaesmer H, Rief W, Keshaviah A, Brähler E, Wilhelm S. The epidemiology of the proposed DSM-5 hoarding disorder: exploration of the acquisition specifier, associated features, and distress. J Clin Psychiatry 2011; 72:780-6; quiz 878-9. [PMID: 21733479 DOI: 10.4088/jcp.10m06380] [Citation(s) in RCA: 127] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 10/20/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Compulsive hoarding, characterized by the acquisition of and failure to discard a large number of possessions, is increasingly recognized as a significant public health burden. Many facets of the phenomenology, including an understanding of the population prevalence and associated features, are not yet fully understood. There is growing evidence that hoarding may warrant its own diagnosis in DSM-5, and it is therefore imperative to investigate the proposed cardinal symptoms along with correlated features that may be diagnostically relevant. METHOD The present investigation examined the point prevalence of hoarding disorder in a nationally representative sample from the German population (N = 2,512). The hoarding definition considered in this study was derived from the Hoarding Rating Scale (HRS) and informed by 3 of the proposed DSM-5 criteria. Several hypothesized core components of hoarding disorder were also assessed using questions from the HRS and the UCLA Hoarding Severity Scale, including types of acquisition, perfectionism, indecision, procrastination, distress, and impairment. Data were collected from May 16, 2009, to June 19, 2009. RESULTS Analyses revealed a current population estimate of 5.8%. Hoarding prevalence did not differ between men and women. Hoarders were significantly more likely to buy items, acquire free things, and steal items they did not need, compared to nonhoarders (P < .001). Perfectionism, indecision, and procrastination were all uniquely and significantly associated with hoarding status (P < .001). Relationships between the proposed core features and distress/impairment are also detailed. CONCLUSIONS The current investigation identified the proposed hoarding disorder as a highly prevalent syndrome; however, it should be noted that we were not able to fully ascertain the DSM-5 criteria and that the current estimate may be higher than the actual population rate. Future research on the diagnostic criteria and associated features will be necessary to help clarify etiologic underpinnings, treatment efforts, and diagnostic nosology.
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Affiliation(s)
- Kiara R Timpano
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL 33146, USA.
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Mischoulon D, Eddy KT, Keshaviah A, Dinescu D, Ross SL, Kass AE, Franko DL, Herzog DB. Depression and eating disorders: treatment and course. J Affect Disord 2011; 130:470-7. [PMID: 21109307 PMCID: PMC3085695 DOI: 10.1016/j.jad.2010.10.043] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2010] [Revised: 10/21/2010] [Accepted: 10/23/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND We examined the course of major depressive disorder (MDD) and predictors of MDD recovery and relapse in a longitudinal sample of women with eating disorders (ED). METHODS 246 Boston-area women with DSM-IV anorexia nervosa-restricting (ANR; n=51), AN-binge/purge (ANBP; n=85), and bulimia nervosa (BN; n=110) were recruited between 1987 and 1991 and interviewed using the Eating Disorders Longitudinal Interval Follow-up Evaluation (LIFE-EAT-II) every 6-12 months for up to 12 years. 100 participants had MDD at study intake and 45 developed MDD during the study. Psychological functioning and treatment were assessed. RESULTS Times to MDD onset (1 week-4.3 years), recovery (8 weeks-8.7 years), and relapse (1 week-5.2 years) varied. 70% recovered from MDD, but 65% subsequently relapsed. ANR patients were significantly less likely to recover from MDD than ANBP patients (p=0.029). Better psychological functioning and history of MDD were associated with higher chance of MDD recovery. Higher baseline depressive severity and full recovery from ED were associated with greater likelihood of MDD relapse; increased weight loss was somewhat protective. Adequate antidepressant treatment was given to 72% of patients with MDD and generally continued after MDD recovery. Time on antidepressants did not predict MDD recovery (p=0.27) or relapse (p=0.26). LIMITATIONS Small ED diagnostic subgroups; lack of non-ED control group. CONCLUSIONS The course of MDD in EDs is protracted; MDD recovery may depend on ED type. Antidepressants did not impact likelihood of MDD recovery, nor protect against relapse, which may impact on treatment strategies for comorbid MDD and EDs.
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Affiliation(s)
- David Mischoulon
- Depression Clinical and Research Program, Massachusetts General Hospital, Boston, MA 02114, USA.
| | - Kamryn T. Eddy
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
,Harvard Medical School, Boston MA 02115, USA
| | - Aparna Keshaviah
- Biostatistics Center, Massachusetts General Hospital, Boston MA 02114, USA
| | - Diana Dinescu
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
| | - Stephanie L. Ross
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
| | - Andrea E. Kass
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
| | - Debra L. Franko
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
,Department of Counseling and Applied Educational Psychology, Northeastern University, Boston MA 02115, USA
| | - David B. Herzog
- Harris Center for Education and Advocacy in Eating Disorders, Department of Psychiatry, Massachusetts General Hospital, Boston MA 02114, USA
,Harvard Medical School, Boston MA 02115, USA
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Steketee G, Siev J, Fama JM, Keshaviah A, Chosak A, Wilhelm S. Predictors of treatment outcome in modular cognitive therapy for obsessive-compulsive disorder. Depress Anxiety 2011; 28:333-41. [PMID: 21308884 PMCID: PMC3076701 DOI: 10.1002/da.20785] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 09/20/2010] [Accepted: 11/06/2010] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND The present study sought to identify predictors of outcome for a comprehensive cognitive therapy (CT) developed for patients with obsessive-compulsive disorder (OCD). METHODS Treatment was delivered over 22 sessions and included standard CT methods, as well as specific strategies designed for subtypes of OCD including religious, sexual, and other obsessions. This study of 39 participants assigned to CT examined predictors of outcomes assessed on the Yale-Brown Obsessive Compulsive Scale. A variety of baseline symptom variables were examined as well as treatment expectancy and motivation. RESULTS Findings indicated that participants who perceived themselves as having more severe OCD at baseline remained in treatment but more severe symptoms were marginally associated with worse outcome for those who completed therapy. Depressed and anxious mood did not predict post-test outcome, but more Axis I comorbid diagnoses (mainly major depression and anxiety disorders), predicted more improvement, as did the presence of sexual (but not religious) OCD symptoms, and stronger motivation (but not expectancy). A small rebound in OCD symptoms at 1-year follow-up was significantly predicted by higher scores on personality traits, especially for schizotypal (but not obsessive-compulsive personality) traits. CONCLUSIONS Longer treatment may be needed for those with more severe symptoms at the outset. CT may have positive effects not only on OCD symptoms but also on comorbid depressive and anxious disorders and associated underlying core beliefs. Findings are discussed in light of study limitations and research on other predictors.
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Affiliation(s)
- Gail Steketee
- Boston University Schoolof Social Work, 264 Bay State Road, Boston, MA 02215, USA.
| | - Jedidiah Siev
- Massachusetts General Hospital and Harvard Medical School
| | - Jeanne M. Fama
- Massachusetts General Hospital and Harvard Medical School
| | | | - Anne Chosak
- Massachusetts General Hospital and Harvard Medical School
| | - Sabine Wilhelm
- Massachusetts General Hospital and Harvard Medical School
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Marques L, LeBlanc N, Weingarden H, Greenberg JL, Traeger LN, Keshaviah A, Wilhelm S. Body dysmorphic symptoms: phenomenology and ethnicity. Body Image 2011; 8:163-7. [PMID: 21354876 DOI: 10.1016/j.bodyim.2010.12.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Revised: 12/21/2010] [Accepted: 12/31/2010] [Indexed: 10/18/2022]
Abstract
Differences in the presentation of clinical features of body dysmorphic disorder (BDD) across ethnic groups have received little investigation. The current study assessed BDD symptoms in an ethnically diverse sample of adults (n=401) using an online survey. Participants completed self-report measures assessing BDD symptoms, body parts of concern and BDD behaviors. Compared to Caucasian participants, no significant differences were found in body parts or behaviors reported by Latino or African American participants. Significant group differences did emerge between Asian and Caucasian participants. Specifically, Asians reported more concern with straight hair and dark skin and fewer body shape concerns than Caucasians. Asians also endorsed lower rates of grooming, touching body parts, and camouflaging and higher rates of exercise compared to Caucasians. Although most clinical features of BDD appear similar across ethnic groups, results showed some differences in body parts and behaviors between Caucasians and Asian Americans with BDD symptoms.
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Affiliation(s)
- Luana Marques
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Simon NM, Wall MM, Keshaviah A, Dryman MT, LeBlanc NJ, Shear MK. Informing the symptom profile of complicated grief. Depress Anxiety 2011; 28:118-26. [PMID: 21284064 PMCID: PMC3079952 DOI: 10.1002/da.20775] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/04/2010] [Accepted: 11/06/2010] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Complicated Grief (CG) is under consideration as a new diagnosis in DSM5. We sought to add empirical support to the current dialogue by examining the commonly used Inventory of Complicated Grief (ICG) scale completed by 782 bereaved individuals. METHODS We employed IRT analyses, factor analyses, and sensitivity and specificity analyses utilizing our full sample (n = 782), and also compared confirmed CG cases (n = 288) to noncases (n = 377). Confirmed CG cases were defined as individuals bereaved at least 6 months who were seeking care for CG, had an ICG ≥ 30, and received a structured clinical interview for CG by a certified clinician confirming CG as their primary illness. Noncases were bereaved individuals who did not present with CG as a primary complaint (including those with depression, bipolar disorder, anxiety disorders, and controls) and had an ICG<25. RESULTS IRT analyses provided guidance about the most informative individual items and their association with CG severity. Factor analyses demonstrated a single factor solution when the full sample was considered, but within CG cases, six symptom clusters emerged: (1) yearning and preoccupation with the deceased, (2) anger and bitterness, (3) shock and disbelief, (4) estrangement from others, (5) hallucinations of the deceased, and (6) behavior change, including avoidance and proximity seeking. The presence of at least one symptom from three different symptom clusters optimized sensitivity (94.8%) and specificity (98.1%). CONCLUSIONS These data, derived from a diverse and predominantly clinical help seeking population, add an important perspective to existing suggestions for DSM5 criteria for CG.
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Affiliation(s)
- Naomi M Simon
- Center for Anxiety and Traumatic Stress Disorders and Complicated Grief Program, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
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Shear MK, Simon N, Wall M, Zisook S, Neimeyer R, Duan N, Reynolds C, Lebowitz B, Sung S, Ghesquiere A, Gorscak B, Clayton P, Ito M, Nakajima S, Konishi T, Melhem N, Meert K, Schiff M, O'Connor MF, First M, Sareen J, Bolton J, Skritskaya N, Mancini AD, Keshaviah A. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety 2011; 28:103-17. [PMID: 21284063 PMCID: PMC3075805 DOI: 10.1002/da.20780] [Citation(s) in RCA: 519] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Bereavement is a severe stressor that typically incites painful and debilitating symptoms of acute grief that commonly progresses to restoration of a satisfactory, if changed, life. Normally, grief does not need clinical intervention. However, sometimes acute grief can gain a foothold and become a chronic debilitating condition called complicated grief. Moreover, the stress caused by bereavement, like other stressors, can increase the likelihood of onset or worsening of other physical or mental disorders. Hence, some bereaved people need to be diagnosed and treated. A clinician evaluating a bereaved person is at risk for both over-and under-diagnosis, either pathologizing a normal condition or neglecting to treat an impairing disorder. The authors of DSM IV focused primarily on the problem of over-diagnosis, and omitted complicated grief because of insufficient evidence. We revisit bereavement considerations in light of new research findings. This article focuses primarily on a discussion of possible inclusion of a new diagnosis and dimensional assessment of complicated grief. We also discuss modifications in the bereavement V code and refinement of bereavement exclusions in major depression and other disorders.
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Dean-Clower E, Doherty-Gilman AM, Keshaviah A, Baker F, Kaw C, Weidong Lu, Manola J, Penson RT, Matulonis UA, Rosenthal DS. Acupuncture as Palliative Therapy for Physical Symptoms and Quality of Life for Advanced Cancer Patients. Integr Cancer Ther 2010; 9:158-67. [DOI: 10.1177/1534735409360666] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background. Acupuncture is underutilized as an adjunct cancer therapy. The main study objectives were to determine the feasibility of administering acupuncture as palliative therapy to patients with advanced ovarian or breast cancer and to assess the effect on symptoms and quality of life (QOL). Methods. This study was a pilot, single-armed prospective clinical trial for patients with advanced cancer to receive 12 acupuncture sessions over 8 weeks with follow-up at weeks 9 and 12. Ambulatory patients with advanced ovarian or breast cancer were enrolled to receive treatments at an outpatient academic oncology center. Symptom severity was measured before and after each acupuncture session. A composite QOL assessment tool, consisting of validated instruments, was completed at 5 time points. Results. Forty patients enrolled in the study. Twenty-eight patients (70%; 95% confidence interval [CI] = 53%-83%) completed 4 weeks of treatment, and 26 patients (65%; 95% CI = 48%-79%) completed 8 weeks. Eight patients (20%) withdrew before receiving acupuncture, and 6 patients (15%) discontinued treatment early because of disease progression or scheduling demands. Among all 32 assessed patients, there was self-reported improvement immediately post-treatment in anxiety, fatigue, pain, and depression and significant improvement over time for patients with anxiety ( P = .001) and depression ( P = .02). Among patients experiencing baseline symptoms, there was improvement in anxiety ( P = .001), fatigue ( P = .0002), pain ( P = .0002), and depression ( P = .003). QOL measures of pain severity and interference, physical and psychological distress, life satisfaction, and mood states showed improved scores during treatment, with sustained benefit at 12 weeks. Conclusions. This pilot study demonstrates that an 8-week outpatient acupuncture course is feasible for advanced cancer patients and produces a measurable benefit that should be evaluated in controlled trials.
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Affiliation(s)
- Elizabeth Dean-Clower
- Dana-Farber Cancer Institute, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | | | | | - Frank Baker
- Center for Medical Outcomes Research, School of Health Sciences & Practice, New York Medical College, Valhalla, NY, USA
| | | | - Weidong Lu
- Dana-Farber Cancer Institute, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | | | - Richard T. Penson
- Massachusetts General Hospital, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | - Ursula A. Matulonis
- Dana-Farber Cancer Institute, Boston, MA, USA, Harvard Medical School, Boston, MA, USA
| | - David S. Rosenthal
- Dana-Farber Cancer Institute, Boston, MA, USA, Harvard Medical School, Boston, MA, USA,
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Wong JS, Taghian AG, Bellon JR, Keshaviah A, Smith BL, Winer EP, Silver B, Harris JR. Tangential radiotherapy without axillary surgery in early-stage breast cancer: results of a prospective trial. Int J Radiat Oncol Biol Phys 2008; 72:866-70. [PMID: 18394815 DOI: 10.1016/j.ijrobp.2008.01.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 01/15/2008] [Accepted: 01/16/2008] [Indexed: 10/22/2022]
Abstract
PURPOSE To determine the risk of regional-nodal recurrence in patients with early-stage, invasive breast cancer, with clinically negative axillary nodes, who were treated with breast-conserving surgery, "high tangential" breast radiotherapy, and hormonal therapy, without axillary surgery or the use of a separate nodal radiation field. METHODS AND MATERIALS Between September 1998 and November 2003, 74 patients who were >/=55 years of age with Stage I-II clinically node-negative, hormone-receptor-positive breast cancer underwent tumor excision to negative margins without axillary surgery as a part of a multi-institutional prospective study. Postoperatively, all underwent high-tangential, whole-breast radiotherapy with a boost to the tumor bed, followed by 5 years of hormonal therapy. RESULTS For the 74 patients enrolled, the median age was 74.5 years, and the median pathologic tumor size was 1.2 cm. Lymphatic vessel invasion was present in 5 patients (7%). At a median follow-up of 52 months, no regional-nodal failures or ipsilateral breast recurrences had been identified (95% confidence interval, 0-4%). Eight patients died, one of metastatic disease and seven of other causes. CONCLUSION In this select group of mainly older patients with early-stage hormone-responsive breast cancer and clinically negative axillary nodes, treatment with high-tangential breast radiotherapy and hormonal therapy, without axillary surgery, yielded a low regional recurrence rate. Such patients might be spared more extensive axillary treatment (axillary surgery, including sentinel node biopsy, or a separate nodal radiation field), with its associated time, expense, and morbidity.
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Affiliation(s)
- Julia S Wong
- Department of Radiation Oncology, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA
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Ligibel JA, Campbell N, Partridge A, Chen WY, Salinardi T, Chen H, Adloff K, Keshaviah A, Winer EP. Impact of a mixed strength and endurance exercise intervention on insulin levels in breast cancer survivors. J Clin Oncol 2008; 26:907-12. [PMID: 18281663 DOI: 10.1200/jco.2007.12.7357] [Citation(s) in RCA: 214] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Accumulating data suggest that exercise may affect breast cancer risk and outcomes. Studies have demonstrated that high levels of insulin, often seen in sedentary individuals, are associated with increased risk of breast cancer recurrence and death. We sought to analyze whether exercise lowered insulin concentrations in breast cancer survivors. METHODS One hundred one sedentary, overweight breast cancer survivors were randomly assigned either to a 16-week cardiovascular and strength training exercise intervention or to a usual care control group. Fasting insulin and glucose levels, weight, body composition, and circumference at the waist and hip were collected at baseline and 16 weeks. RESULTS Baseline and 16-week measurements were available for 82 patients. Fasting insulin concentrations decreased by an average of 2.86 microU/mL in the exercise group (P = .03), with no significant change in the control group (decrease of 0.27 microU/mL, P = .65). The change in insulin levels in the exercise group seemed greater than the change in controls, but the comparison did not reach statistical significance (P = .07). There was a trend toward improvement in insulin resistance in the exercise group (P = .09) but no change in fasting glucose levels. The exercise group also experienced a significant decrease in hip measurements, with no change in weight or body composition. CONCLUSION Participation in an exercise intervention was associated with a significant decrease in insulin levels and hip circumference in breast cancer survivors. The relationship between physical activity and breast cancer prognosis may be mediated, in part, through changes in insulin levels and/or changes in body fat or fat deposition.
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Affiliation(s)
- Jennifer A Ligibel
- Dana-Farber Cancer Institute, Brigham and Women's Hospital, Harvard Medical School, Channing Laboratory, Boston, MA, USA.
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Mouridsen H, Keshaviah A, Coates AS, Rabaglio M, Castiglione-Gertsch M, Sun Z, Thürlimann B, Mauriac L, Forbes JF, Paridaens R, Gelber RD, Colleoni M, Smith I, Price KN, Goldhirsch A. Cardiovascular Adverse Events During Adjuvant Endocrine Therapy for Early Breast Cancer Using Letrozole or Tamoxifen: Safety Analysis of BIG 1-98 Trial. J Clin Oncol 2007; 25:5715-22. [DOI: 10.1200/jco.2007.12.1665] [Citation(s) in RCA: 106] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Previous analyses of adjuvant studies of aromatase inhibitors versus tamoxifen, including the Breast International Group (BIG) 1-98 study, have suggested a small numerical excess of cardiac adverse events (AEs) on aromatase inhibitors, a reduction in the incidence of hypercholesterolemia on tamoxifen, and significantly higher incidence of thromboembolic AEs on tamoxifen. The purpose of the present study is to provide detailed updated information on these AEs in BIG 1-98. Patients and Methods Eight thousand twenty-eight postmenopausal women with receptor-positive early breast cancer were randomly assigned (double-blind) between March 1998 and May 2003 to receive 5 years of adjuvant endocrine therapy with letrozole, tamoxifen, or a sequence of these agents. Seven thousand nine hundred sixty-three patients who actually received therapy are included in this safety analysis, which focuses on cardiovascular events. AE recording ceased 30 days after therapy completion (or after switch on the sequential arms). Results Baseline comorbidities were balanced. At a median follow-up time of 30.1 months, we observed similar overall incidence of cardiac AEs (letrozole, 4.8%; tamoxifen, 4.7%), more grade 3 to 5 cardiac AEs on letrozole (letrozole, 2.4%; tamoxifen, 1.4%; P = .001)—an excess only partially attributable to prior hypercholesterolemia—and more overall (tamoxifen, 3.9%; letrozole, 1.7%; P < .001) and grade 3 to 5 thromboembolic AEs on tamoxifen (tamoxifen, 2.3%; letrozole, 0.9%; P < .001). There was no significant difference between tamoxifen and letrozole in incidence of hypertension or cerebrovascular events. Conclusion The present safety analysis, limited to cardiovascular AEs in BIG 1-98, documents a low overall incidence of cardiovascular AEs, which differed between treatment arms.
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Affiliation(s)
- Henning Mouridsen
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Aparna Keshaviah
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Alan S. Coates
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Manuela Rabaglio
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Monica Castiglione-Gertsch
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Zhuoxin Sun
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Beat Thürlimann
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Louis Mauriac
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - John F. Forbes
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Robert Paridaens
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Richard D. Gelber
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Marco Colleoni
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Ian Smith
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Karen N. Price
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Aron Goldhirsch
- From the Danish Breast Cancer Cooperative Group, Rigshospitalet, Copenhagen, Denmark; International Breast Cancer Study Group (IBCSG) Statistical Center, Dana-Farber Cancer Institute; Harvard School of Public Health; Frontier Science and Technology Research Foundation, Boston, MA; IBCSG Coordinating Center and Inselspital; Swiss Group for Clinical Cancer Research, Bern; Senology Center of Eastern Switzerland, Kantonsspital, St Gallen; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
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Burstein HJ, Keshaviah A, Baron AD, Hart RD, Lambert-Falls R, Marcom PK, Gelman R, Winer EP. Trastuzumab plus vinorelbine or taxane chemotherapy for HER2-overexpressing metastatic breast cancer: the trastuzumab and vinorelbine or taxane study. Cancer 2007; 110:965-72. [PMID: 17614302 DOI: 10.1002/cncr.22885] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND The optimal trastuzumab-based chemotherapy regimen for HER2-overexpressing, metastatic breast cancer is not known. The trastuzumab and vinorelbine or taxane (TRAVIOTA) study was a prospective, multicenter, randomized trial that was designed to compare these regimens. METHODS Eligible patients had HER2-overexpressing, metastatic breast cancer and had received no prior chemotherapy for advanced disease. Patients were randomized 1:1 to receive either trastuzumab with weekly vinorelbine therapy or weekly taxane therapy (paclitaxel or docetaxel at the investigator's choice). Originally planned for 250 patients, the study was closed because of poor accrual with 81 evaluable patients, including 41 patients who received vinorelbine and 40 patients who received taxane. RESULTS Response rates were 51% and 40% for the vinorelbine/trastuzumab arm and the taxane/trastuzumab arm, respectively (Fisher exact test; P = .37). The median time to disease progression was 8.5 months and 6.0 months for the vinorelbine- and taxane-based arms, respectively (log-rank test; P = .09). Treatment with either regimen generally was well tolerated, yielding comparable rates of neurologic and gastrointestinal toxicity. Vinorelbine-based treatment was associated with more anemia and neutropenia and with 2 episodes of cardiotoxicity. Taxane-based therapy was associated with more dermatologic toxicity, myalgias, and fluid retention. CONCLUSIONS Both vinorelbine/trastuzumab and taxane/trastuzumab treatments were active as first-line therapy for HER2-positive, metastatic breast cancer and had comparable rates of efficacy and tolerability. The toxicities observed were the result of recognized side effects associated with each of the chemotherapy agents and schedules. These data can inform treatment decision making in this clinical setting.
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Affiliation(s)
- Harold J Burstein
- Dana-Farber Cancer Institute and Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Beard C, Dean-Clower E, Dusek J, Stason WB, DeCristofaro S, Keshaviah A, Purevjal I, Rosenthal D, Webster A, Benson H. A study of complementary therapies in men receiving radiation therapy for prostate cancer: A randomized feasibility trial. J Clin Oncol 2007. [DOI: 10.1200/jco.2007.25.18_suppl.15638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
15638 Background: Prostate-cancer patients suffer from substantial distress with both their diagnosis and treatment. Several studies have looked at the use of complementary and alternative medicine (CAM) in patients with prostate cancer to alleviate their stress and effects of therapy. We elected to study Reiki and Relaxation Response Therapy (RRT) in prostate-cancer patients. Methods: Patients receiving an eight-week course of radiation for prostate cancer were eligible. Consented participants were randomly assigned to RRT, to Reiki, or to no CAM therapy during radiotherapy. Reiki was given twice weekly, RRT once weekly. The feasibility of enrolling 60 patients, their compliance with physiologic and psychological testing, and preliminary assessment of the effect of CAM are the study endpoints. Statistical analysis of feasibility is based on the assumption that at least 80% of patients would complete 14/16 Reiki sessions or 7/8 RRT sessions. Patients were tested for outcome measures at baseline, at randomization, halfway through radiation, at completion of radiation and 2 months later. The psychosocial outcome measures used were the STAI, CES-D, FACT-G, FACIT: Fatigue Scale, and EPIC: Hormone Section. Physiological assessment included salivary cortisol, blood samples for interleukin-6, tumor necrosis factor alpha, CD8, natural killer cells, heat shock protein 70 and a validated bowel-and-bladder-symptom questionnaire. Results: We have enrolled 62 of 108 eligible patients (60%) within 18 months. The number of enrollment has been increased to 62 as two patients changed their treatment location. To date five patients dropped out short of completion, 1 became ineligible, 32 have completed the study, 20 are still receiving CAM therapy or are in active follow-up and 2 are awaiting randomization and radiotherapy. Conclusions: Complementary therapy appears to be of much interest to prostate-cancer patients. At the completion of the trial, we will have more data on feasibility, compliance and preliminary results on the effect of CAM intervention in this population. No significant financial relationships to disclose.
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Affiliation(s)
- C. Beard
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - E. Dean-Clower
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - J. Dusek
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - W. B. Stason
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - S. DeCristofaro
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - A. Keshaviah
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - I. Purevjal
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - D. Rosenthal
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - A. Webster
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
| | - H. Benson
- Brigham and Women's Hospital, Boston, MA; Dana-Farber Cancer Institute, Boston, MA; Massachusetts General Hospital, Boston, MA; Harvard School of Public Health, Boston, MA
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Mauriac L, Keshaviah A, Debled M, Mouridsen H, Forbes JF, Thürlimann B, Paridaens R, Monnier A, Láng I, Wardley A, Nogaret JM, Gelber RD, Castiglione-Gertsch M, Price KN, Coates AS, Smith I, Viale G, Rabaglio M, Zabaznyi N, Goldhirsch A. Predictors of early relapse in postmenopausal women with hormone receptor-positive breast cancer in the BIG 1-98 trial. Ann Oncol 2007; 18:859-67. [PMID: 17301074 DOI: 10.1093/annonc/mdm001] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Aromatase inhibitors are considered standard adjuvant endocrine treatment of postmenopausal women with hormone receptor-positive breast cancer, but it remains uncertain whether aromatase inhibitors should be given upfront or sequentially with tamoxifen. Awaiting results from ongoing randomized trials, we examined prognostic factors of an early relapse among patients in the BIG 1-98 trial to aid in treatment choices. PATIENTS AND METHODS Analyses included all 7707 eligible patients treated on BIG 1-98. The median follow-up was 2 years, and the primary end point was breast cancer relapse. Cox proportional hazards regression was used to identify prognostic factors. RESULTS Two hundred and eighty-five patients (3.7%) had an early relapse (3.1% on letrozole, 4.4% on tamoxifen). Predictive factors for early relapse were node positivity (P < 0.001), absence of both receptors being positive (P < 0.001), high tumor grade (P < 0.001), HER-2 overexpression/amplification (P < 0.001), large tumor size (P = 0.001), treatment with tamoxifen (P = 0.002), and vascular invasion (P = 0.02). There were no significant interactions between treatment and the covariates, though letrozole appeared to provide a greater than average reduction in the risk of early relapse in patients with many involved lymph nodes, large tumors, and vascular invasion present. CONCLUSION Upfront letrozole resulted in significantly fewer early relapses than tamoxifen, even after adjusting for significant prognostic factors.
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Affiliation(s)
- L Mauriac
- French Breast Cancer Group, Institut Bergonié Bordeaux, France.
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Keshaviah A, Dellapasqua S, Rotmensz N, Lindtner J, Crivellari D, Collins J, Colleoni M, Thürlimann B, Mendiola C, Aebi S, Price KN, Pagani O, Simoncini E, Castiglione Gertsch M, Gelber RD, Coates AS, Goldhirsch A. CA15-3 and alkaline phosphatase as predictors for breast cancer recurrence: a combined analysis of seven International Breast Cancer Study Group trials. Ann Oncol 2007; 18:701-8. [PMID: 17237474 DOI: 10.1093/annonc/mdl492] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND We evaluated the ability of CA15-3 and alkaline phosphatase (ALP) to predict breast cancer recurrence. PATIENTS AND METHODS Data from seven International Breast Cancer Study Group trials were combined. The primary end point was relapse-free survival (RFS) (time from randomization to first breast cancer recurrence), and analyses included 3953 patients with one or more CA15-3 and ALP measurement during their RFS period. CA15-3 was considered abnormal if >30 U/ml or >50% higher than the first value recorded; ALP was recorded as normal, abnormal, or equivocal. Cox proportional hazards models with a time-varying indicator for abnormal CA15-3 and/or ALP were utilized. RESULTS Overall, 784 patients (20%) had a recurrence, before which 274 (35%) had one or more abnormal CA15-3 and 35 (4%) had one or more abnormal ALP. Risk of recurrence increased by 30% for patients with abnormal CA15-3 [hazard ratio (HR) = 1.30; P = 0.0005], and by 4% for those with abnormal ALP (HR = 1.04; P = 0.82). Recurrence risk was greatest for patients with either (HR = 2.40; P < 0.0001) and with both (HR = 4.69; P < 0.0001) biomarkers abnormal. ALP better predicted liver recurrence. CONCLUSIONS CA15-3 was better able to predict breast cancer recurrence than ALP, but use of both biomarkers together provided a better early indicator of recurrence. Whether routine use of these biomarkers improves overall survival remains an open question.
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Affiliation(s)
- A Keshaviah
- International Breast Cancer Study Group Statistical Center, Dana-Farber Cancer Institute, Boston, MA, USA
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Coates AS, Keshaviah A, Thürlimann B, Mouridsen H, Mauriac L, Forbes JF, Paridaens R, Castiglione-Gertsch M, Gelber RD, Colleoni M, Láng I, Del Mastro L, Smith I, Chirgwin J, Nogaret JM, Pienkowski T, Wardley A, Jakobsen EH, Price KN, Goldhirsch A. Five years of letrozole compared with tamoxifen as initial adjuvant therapy for postmenopausal women with endocrine-responsive early breast cancer: update of study BIG 1-98. J Clin Oncol 2007; 25:486-92. [PMID: 17200148 DOI: 10.1200/jco.2006.08.8617] [Citation(s) in RCA: 662] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Previous analyses of the Breast International Group (BIG) 1-98 four-arm study compared initial therapy with letrozole or tamoxifen including patients randomly assigned to sequential treatment whose information was censored at the time of therapy change. Because this presentation may unduly reflect early events, the present analysis is limited to patients randomly assigned to the continuous therapy arms and includes protocol-defined updated results. PATIENTS AND METHODS Four thousand nine hundred twenty-two of the 8,028 postmenopausal women with receptor-positive early breast cancer randomly assigned (double-blind) to the BIG 1-98 trial were assigned to 5 years of continuous adjuvant therapy with either letrozole or tamoxifen; the remainder of women were assigned to receive the agents in sequence. Disease-free survival (DFS) was the primary end point. RESULTS At a median follow-up time of 51 months, we observed 352 DFS events among 2,463 women receiving letrozole and 418 events among 2,459 women receiving tamoxifen. This reflected an 18% reduction in the risk of an event (hazard ratio, 0.82; 95% CI, 0.71 to 0.95; P = .007). No predefined subsets showed differential benefit. Adverse events were similar to previous reports. Patients on tamoxifen experienced more thromboembolic events, endometrial pathology, hot flashes, night sweats, and vaginal bleeding. Patients on letrozole experienced more bone fractures, arthralgia, low-grade hypercholesterolemia, and cardiovascular events other than ischemia and cardiac failure. CONCLUSION The present updated analysis, which was limited to patients on monotherapy arms in BIG 1-98, yields results similar to those from the previous primary analysis but more directly comparable with results from other trials of continuous therapy using a single endocrine agent.
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Affiliation(s)
- Alan S Coates
- International Breast Cancer Study Group (IBCSG), IBCSG Coordinating Center, Bern, Switzerland.
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Mouridsen HT, Keshaviah A, Mauriac L, Forbes J, Paridaens R, Castiglione-Gertsch M, Gelber R, Smith I, Thuerlimann B, Goldhirsch A. BIG 1–98: A randomized double-blind phase III study comparing letrozole and tamoxifen given in sequence vs. alone as adjuvant endocrine therapy for postmenopausal women with receptor-positive breast cancer. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.lba528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
LBA528 Background: The Primary Core Analysis (PCA) of BIG 1–98 comparing letrozole (L) to tamoxifen (T) as initial adjuvant endocrine therapy showed that L significantly prolonged disease-free survival (DFS), particularly reducing the risk of relapse in distant sites, compared with T for postmenopausal women with endocrine-responsive breast cancer (BC). The aim of the Second Primary Analysis (SPA) is to compare L and T given in sequence vs. alone. On Mar 15, ‘06, the Data Safety Monitoring Committee (DSMC) will review the results of the 2nd interim analysis of the SPA. We will present safety and efficacy data from this analysis if the DSMC recommends release of the results. Methods: 8028 women were randomized upfront to Tx5 years (yrs) (A), Lx5 (B), Tx2→Lx3 (C), or Lx2→Tx3 (D); 1835 to the 2-arm option of the study (arm A vs. B; Mar ’98 - Mar ‘00) and 6193 to the 4-arm option (arm A vs. B vs. C vs. D; Apr ’99 - May ‘03). The primary endpoint was DFS (time from randomization to first occurrence of invasive BC recurrence, invasive contralateral BC, second non-breast malignancy, or death from any cause). The SPA is comprised of two pair-wise comparisons: arm A vs. C and B vs. D. Only 4-arm patients (pts) alive and disease-free at 2 yrs after study entry (corresponding to the treatment switch for arms C and D) are included. These analyses will determine if the risk of an event beyond 2 yrs is reduced by switching agents. Additional exploratory analyses based on all events and follow-up (FU) for 4-arm pts will be conducted, including the comparison of arm B vs. C. The final SPA is planned for Feb ‘08, after 662 events. In Jan ‘05, the 1st interim efficacy analysis was presented to the DSMC, after 162 events among 3641 pts (excluding those who had an event within 2 yrs or did not yet have at least 2 yrs of FU). The median SPA FU (from 2 yrs after study entry) was 11.1 months. The 2nd interim efficacy analysis will be presented to the DSMC on Mar 15, ‘06 based on data received as of a Dec 21, ‘05. Results: Conclusions: No significant financial relationships to disclose.
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Affiliation(s)
| | - A. Keshaviah
- International Breast Cancer Study Group, Bern, Switzerland
| | - L. Mauriac
- International Breast Cancer Study Group, Bern, Switzerland
| | - J. Forbes
- International Breast Cancer Study Group, Bern, Switzerland
| | - R. Paridaens
- International Breast Cancer Study Group, Bern, Switzerland
| | | | - R. Gelber
- International Breast Cancer Study Group, Bern, Switzerland
| | - I. Smith
- International Breast Cancer Study Group, Bern, Switzerland
| | - B. Thuerlimann
- International Breast Cancer Study Group, Bern, Switzerland
| | - A. Goldhirsch
- International Breast Cancer Study Group, Bern, Switzerland
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Burstein HJ, Keshaviah A, Baron A, Hart R, Lambert-Falls R, Marcom PK, Gelman R, Winer EP. Trastuzumab and vinorelbine or taxane chemotherapy for HER2+ metastatic breast cancer: The TRAVIOTA study. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.650] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
650 Background: The optimal trastuzumab/chemotherapy regimen for advanced breast cancer is not known. We performed a multicenter, randomized clinical trial to compare TRastuzumab And VInorebline Or TAxane (TRAVIOTA) chemo- and bio-therapy combination treatment given on a weekly schedule for HER2+ metastatic breast cancer. Patients and Methods: Eligible patients had stage IV breast cancer, measurable disease (by RECIST criteria), HER2+ tumors (IHC 3+ or FISH+), no prior chemotherapy or trastuzumab for advanced breast cancer, and LVEF > 50%. Patients were randomized 1:1 to trastuzumab (4 mg/kg loading dose, 2 mg/kg weekly thereafter) with either weekly vinorelbine (25 mg/m2) or weekly taxane (paclitaxel 80 mg/m2 or docetaxel 35 mg/m2, selected by the treating investigator). The primary endpoint was response rate. The study opened in August 2001 and planned to accrue 250 patients. It was closed in December 2003 having accrued only 85 patients. Results are presented for the 81 patients who received any protocol-based therapy. Results: Patients receiving trastuzumab and vinorelbine tended to have higher response rates and TTP than those assigned trastuzumab and taxane therapy but the results were not statistically significant (see Table ). Vinorelbine therapy was associated with more frequent grade 3 or 4 hematological toxicity and dose delay because of myelosuppression. Other toxicities generally reflected the known side effects of the chemotherapy agents. Conclusions: The TRAVIOTA study suggests at least comparable clinical activity of trastuzumab with vinorelbine as with weekly taxane chemotherapy in HER2+ metastatic breast cancer, with side effect profiles consistent with previous experience with these regimens. [Table: see text] [Table: see text]
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Affiliation(s)
- H. J. Burstein
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - A. Keshaviah
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - A. Baron
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - R. Hart
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - R. Lambert-Falls
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - P. K. Marcom
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - R. Gelman
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
| | - E. P. Winer
- Dana-Farber Cancer Institute, Boston, MA; California Pacific Medical Center, San Francisco, CA; Oncology Alliance, Milwaukee, WI; SC Oncology, Columbia, SC; Duke University Medical Center, Durham, NC
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Ligibel JA, Chen W, Keshaviah A, Adloff K, Partridge A, Salinardi T, Winer EP. The impact of an exercise intervention on body composition, fat distribution, and weight in breast cancer survivors. J Clin Oncol 2006. [DOI: 10.1200/jco.2006.24.18_suppl.590] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
590 Background: Recent research has demonstrated that obesity increases a woman’s risk of breast cancer recurrence. Although the mechanism is not well understood, it is known that obese women have higher levels of insulin and other hormones related to energy balance. In this study, we sought to explore the impact of an exercise intervention on body composition, fat distribution, weight, and insulin levels in a population of breast cancer survivors. Methods: Inactive women with early stage breast cancer who had completed adjuvant chemotherapy and/or radiation were randomized to a 16-week exercise intervention or a normal care control group. The exercise intervention consisted of supervised strength training and unsupervised cardiovascular exercise, with a goal of 2 strength training sessions and 90 minutes of cardiovascular exercise each week. Measurement of weight, body composition, and circumference at the waist and hip, were collected at baseline and after 16 weeks in both groups. Fasting blood samples were also collected at these two time points for insulin and glucose levels, so that changes in these levels between the intervention and control groups could be compared. Results: Eighty-five women have been randomized; complete anthropometric data are presently available for 51. Women in the exercise group experienced a nonsignificant decrease in body weight, body fat, and circumference at the waist and hip, as compared to control patients. Participants completed a median of 84% of scheduled strength training sessions and 80% of recommended cardiovascular sessions. Strength increased by an average of 40% during the exercise intervention. Prior studies have demonstrated significant inter-assay variability in biomarker testing, thus insulin and glucose testing will be performed when all patients have completed the protocol. Conclusions: Compliance with the exercise intervention was good. Women in the exercise group experienced non-significant changes in anthropometric measures, and increased strength during the 16-week intervention. Final strength and anthropometric data from the entire cohort will be available for presentation. This project was supported by an ASCO Career Development Award and funding from the Lance Armstrong Foundation. No significant financial relationships to disclose.
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Affiliation(s)
| | - W. Chen
- Dana-Farber Cancer Institute, Boston, MA
| | | | - K. Adloff
- Dana-Farber Cancer Institute, Boston, MA
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