Factors impacting intent to seek treatment within youth at clinical high risk for psychosis

Existing work indicates that there is unmet need for care in those at clinical high risk (CHR) for psychosis. However, research on the factors that drive treatment seeking behaviors in this population is limited. Further, it is unknown how help-seeking behavior in CHR individuals compares to those seen in mood disorders, who have a higher rate of treatment seeking behavior. Participants (n = 559) completed an assessment of their intent to seek mental health treatment, attenuated psychosis-risk symptoms, and psychiatric symptoms and diagnoses. Participants were divided into CHR (n = 91), Mood Disorders (MD) (n = 72), or Community Controls (CC) groups (n = 396), whose intent to seek treatment was compared. Associations between intent to seek treatment with past treatment, depression, anxiety, positive and negative symptoms, distress from symptoms, intelligence quotient (IQ) estimates, and insight were assessed in CHR individuals. Further, it was assessed how this differs for the MD group. The MD group reported higher intent to seek treatment than CHR individuals, which reported higher intent to seek treatment than the CC group. In those at CHR, previous treatment, greater depression and anxiety severity, and higher distress all independently predicted higher intent to seek treatment. Depression predicted intent to seek treatment in both MD and CHR individuals. Previous treatment predicted intent to seek treatment in those at CHR. Our findings suggest that depression and past treatment utilization are critical factors in increasing intent to seek treatment in those at CHR, potentially serving as important targets for engaging this population in treatment.

Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ): Rationale and Study Design of the Largest Global Prospective Cohort Study of Clinical High Risk for Psychosis

This article describes the rationale, aims, and methodology of the Accelerating Medicines Partnership® Schizophrenia (AMP® SCZ). This is the largest international collaboration to date that will develop algorithms to predict trajectories and outcomes of individuals at clinical high risk (CHR) for psychosis and to advance the development and use of novel pharmacological interventions for CHR individuals. We present a description of the participating research networks and the data processing analysis and coordination center, their processes for data harmonization across 43 sites from 13 participating countries (recruitment across North America, Australia, Europe, Asia, and South America), data flow and quality assessment processes, data analyses, and the transfer of data to the National Institute of Mental Health (NIMH) Data Archive (NDA) for use by the research community. In an expected sample of approximately 2000 CHR individuals and 640 matched healthy controls, AMP SCZ will collect clinical, environmental, and cognitive data along with multimodal biomarkers, including neuroimaging, electrophysiology, fluid biospecimens, speech and facial expression samples, novel measures derived from digital health technologies including smartphone-based daily surveys, and passive sensing as well as actigraphy. The study will investigate a range of clinical outcomes over a 2-year period, including transition to psychosis, remission or persistence of CHR status, attenuated positive symptoms, persistent negative symptoms, mood and anxiety symptoms, and psychosocial functioning. The global reach of AMP SCZ and its harmonized innovative methods promise to catalyze the development of new treatments to address critical unmet clinical and public health needs in CHR individuals.

Diminished differentiation of rewards in individuals at clinical high-risk for psychosis

Reward processing is impaired in people with schizophrenia, which may begin in the clinical high-risk (CHR) for psychosis period. The Monetary Incentive Delay (MID) task has been important in understanding the neural correlates of reward processing deficits in various psychiatric disorders. Previous research has found that CHR individuals have an imprecise mental representation of rewards, which leads to a diminished differentiation between rewards, though this has not been observed behaviorally. A total of 19 CHR individuals and 20 controls were given a novel variant of the MID task, designed to examine how modulating reward context may impact responses to reward cues, a process often referred to as "adaptive coding." Both groups appeared to update their behavior in response to the rewards available in this adaptive task. However, when compared to controls who showed a more graded decrease in response time to increasing reward contexts, CHR individuals appeared to have a sharp decrease in response time in the low reward context that is nearly stable across higher reward contexts. This is largely driven by the exponential component of the response time distribution, which is often interpreted to be more cognitively or effortfully influenced. Response times are related to negative symptoms, but not positive symptoms, disorganized symptoms, or estimated intelligence. Although an adaptive coding effect was not observed, these results provide novel insight into the reward processing mechanisms and volitional processes in the CHR population, as this was the first study to observe the diminished differentiation of rewards behaviorally.

Value Representations of Spite Sensitivity in Psychosis on the Minnesota Trust Game

BACKGROUND

Spite sensitivity provides a valuable construct to understand persecutory ideation and its underlying neural mechanisms. We examined the relationship between persecution and spite sensitivity in psychosis to identify their neural substrates.

METHODS

In a 3T magnetic resonance imaging scanner, 49 participants with psychosis played the Minnesota Trust Game, in which they decided whether to take a small amount of money or trust a partner to choose between fair and unfair distributions of money. In some conditions, the partner benefited from the unfair option, while in others, the partner lost money. Participants who were untrusting in the second condition (suspiciousness) showed heightened sensitivity to spite. Behavioral measures included mistrust during the 2 conditions of the game, which were compared with Brief Psychiatric Rating Scale persecution and computational modeling. Functional connectivity and blood oxygen level-dependent analyses were also conducted on a priori regions during spite-sensitive decisions.

RESULTS

Behavioral results replicated previous findings; participants who experienced more persecutory ideation trusted less, specifically in the suspiciousness condition. Functional connectivity findings showed that decreased connectivity between the orbitofrontal cortex-insula and the left frontoparietal network was associated with increased persecutory ideation and estimated spite-guilt (a marker of spite sensitivity). Additionally, we found differences between conditions in caudate nucleus, medial prefrontal cortex, and lateral orbitofrontal cortex activation.

CONCLUSIONS

These findings provide a new perspective on the origin of positive symptoms by identifying primary brain circuits that are related to both spite sensitivity and persecutory ideation.

Do the Components of Attenuated Positive Symptoms Truly Represent One Construct?

BACKGROUND AND HYPOTHESES

Psychosis-risk inventories, like the Structured Interview for Psychosis-Risk Syndromes (SIPS), utilize symptom components and coalesce the information into a single-severity rating. These components include frequency, duration, in-the-moment conviction, retrospective insight, distress, and effect on social/role functioning. While combining components distills a great deal of important information into one practical symptom rating, this approach may mask important details of the greater clinical picture.

STUDY DESIGN

Individuals at clinical high risk for psychosis (n = 115) were assessed with the SIPS Score Separable Components (SSSC) scale, created to accompany the SIPS positive items by dividing each item into the 7 components identified above. The latent structure of the SSSC was identified with an exploratory factor analysis (EFA). The factors were followed up with validation analyses including hypothesized cognitive, functioning, and symptom measures. Finally, clinical utility analyses were conducted to understand relationships between psychosis risk and common comorbidities.

STUDY RESULTS

EFA revealed that the SSSC had 3 interpretable factors with the appropriate fit (rmsr = 0.018, TLI = 0.921): Conviction (in-the-moment conviction, retrospective insight), Distress-Impairment (distress, social/role functioning), and Frequency/Duration (frequency, duration). Conviction was minimally valid, Distress-Impairment had excellent validity, and Frequency/Duration was not related to any of the candidate validators. Conviction significantly predicted elevated psychosis risk. Distress-Impairment was related to common comorbid symptoms. Notably, the factors associated more strongly with clinical features than the traditional SIPS scores.

CONCLUSIONS

The SSSC offers a supplemental approach to single-severity ratings, providing useful clinical insight, mechanistic understanding, and the potential for better capturing heterogeneity in this population.

Comparing a Computerized Digit Symbol Test to a Pen-and-Paper Classic

Background and Hypothesis

Processing speed dysfunction is a core feature of psychosis and predictive of conversion in individuals at clinical high risk (CHR) for psychosis. Although traditionally measured with pen-and-paper tasks, computerized digit symbol tasks are needed to meet the increasing demand for remote assessments. Therefore we: (1) assessed the relationship between traditional and computerized processing speed measurements; (2) compared effect sizes of impairment for progressive and persistent subgroups of CHR individuals on these tasks; and (3) explored causes contributing to task performance differences.

Study Design

Participants included 92 CHR individuals and 60 healthy controls who completed clinical interviews, the Brief Assessment of Cognition in Schizophrenia Symbol Coding test, the computerized TestMyBrain Digit Symbol Matching Test, a finger-tapping task, and a self-reported motor abilities measure. Correlations, Hedges' g, and linear models were utilized, respectively, to achieve the above aims.

Study Results

Task performance was strongly correlated (r = 0.505). A similar degree of impairment was seen between progressive (g = -0.541) and persistent (g = -0.417) groups on the paper version. The computerized task uniquely identified impairment for progressive individuals (g = -477), as the persistent group performed similarly to controls (g = -0.184). Motor abilities were related to the computerized version, but the paper version was more related to symptoms and psychosis risk level.

Conclusions

The paper symbol coding task measures impairment throughout the CHR state, while the computerized version only identifies impairment in those with worsening symptomatology. These results may be reflective of sensitivity differences, an artifact of existing subgroups, or evidence of mechanistic differences.

Reliability and Replicability of Implicit and Explicit Reinforcement Learning Paradigms in People With Psychotic Disorders

BACKGROUND

Motivational deficits in people with psychosis may be a result of impairments in reinforcement learning (RL). Therefore, behavioral paradigms that can accurately measure these impairments and their change over time are essential.

METHODS

We examined the reliability and replicability of 2 RL paradigms (1 implicit and 1 explicit, each with positive and negative reinforcement components) given at 2 time points to healthy controls (n = 75), and people with bipolar disorder (n = 62), schizoaffective disorder (n = 60), and schizophrenia (n = 68).

RESULTS

Internal consistency was acceptable (mean α = 0.78 ± 0.15), but test-retest reliability was fair to low (mean intraclass correlation = 0.33 ± 0.25) for both implicit and explicit RL. There were no clear effects of practice for these tasks. Largely, performance on these tasks shows intact implicit and impaired explicit RL in psychosis. Symptom presentation did not relate to performance in any robust way.

CONCLUSIONS

Our findings replicate previous literature showing spared implicit RL and impaired explicit reinforcement in psychosis. This suggests typical basal ganglia dopamine release, but atypical recruitment of the orbitofrontal and dorsolateral prefrontal cortices. However, we found that these tasks have only fair to low test-retest reliability and thus may not be useful for assessing change over time in clinical trials.

Abstract P2-11-07: Evaluation of lung and heart dose in patients treated with radiation for breast cancer

BACKGROUND: A recent systematic review of women receiving radiation therapy (RT) for breast cancer combined with modeled estimated risks of mortality from heart disease and lung cancer found that the mean heart dose (MHD) was 4.4 Gy (5.2 Gy for left-sided, 3.7Gy for right-sided) and the mean total lung dose (TLD) was 5.7 Gy. Estimated excess cardiac mortality ranged from 0.3-1.2% and lung cancer mortality ranged from 0.2-4.4% with modern RT. Using these data as a benchmark, we set to review the MHD and mean TLD for our patients receiving adjuvant breast RT in a modern era when RT planning includes meeting normal tissue constraints.

METHODS: We evaluated the MHD and mean TLD for patients with unilateral breast cancer treated with curative intent between January 2012 and May 2017 at our institution. Dosimetric data was complete for 793 patients. During this time period the MHD constraint was 4 Gy and lung V20 was 20% for breast only and 35% for regional nodal irradiation (RNI). RNI included the axillary, supraclavicular and internal mammary nodes.. Patients were evaluated by laterality (right vs. left), prone vs. supine position, breast only whole breast irradiation (WBI) and RNI with intact breast or chestwall post-mastectomy. The RNI group was examined by treatment technique, intensity modulated radiation therapy (IMRT) vs. 3D conformal (3DCRT). We compared differences in the MHD and mean TLD within those groups using the Student's t-test.

RESULTS: We identified 651 patients: 481 WBI only and 170 RNI. In the RNI group, 77 (45.3%) received IMRT. Of the WBI only group, 229 (47.6%) were right-sided and 313 (65.1%) were treated prone. The mean TLD for the WBI only group was significantly lower in the prone vs. supine position (0.62 Gy vs. 3.90 Gy, p<0.0001). The prone position resulted in lower MHD for both left-sided WBI (1.17 Gy vs. 1.67 Gy, p<0.0001) and right-sided WBI (0.51 Gy vs. 0.64 Gy, p=0.1067). In patients that received RNI, the mean TLD was 8.20 Gy (SD 1.03) and the MHD was 2.67 Gy (3.25 Gy for left-sided vs. 1.83 Gy for right-sided, p=0.0001). Compared to 3DCRT, IMRT increased the MHD (2.46 Gy vs. 4.23 Gy for left-sided, p<0.0001; 0.94 Gy vs. 2.85 Gy, p<0.0001 for right-sided) and mean TLD (8.50 Gy vs. 7.95 Gy, p=0.0005).

CONCLUSIONS: In the era of RT treatment planning that incorporates normal tissue constraints, very low MHD and lower TLD are achievable in prone or supine position patients receiving WBI only for breast conserving treatment. This means lower late cardiac and lung cancer mortality risks from RT. Women that receive RNI also have acceptably low MHD but high mean TLD. Node positive breast cancer patients derive a disease free survival benefit from RNI, which must be balanced against potential late risk for lung cancer, especially in smokers. More attention should be focused on identifying lung cancer risk, smoking cessation and screening efforts in node positive breast cancer patients with indications for RNI to minimize late radiation risks.

Citation Format: Healy EH, Pratt DN, DiCostanzo D, Bazan JG, White J. Evaluation of lung and heart dose in patients treated with radiation for breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-11-07.

Attacking Heterogeneity in Schizophrenia by Deriving Clinical Subgroups From Widely Available Symptom Data

Previous research has identified (1) a "deficit" subtype of schizophrenia characterized by enduring negative symptoms and diminished emotionality and (2) a "distress" subtype associated with high emotionality-including anxiety, depression, and stress sensitivity. Individuals in deficit and distress categories differ sharply in development, clinical course and behavior, and show distinct biological markers, perhaps signaling different etiologies. We tested whether deficit and distress subtypes would emerge from a simple but novel data-driven subgrouping analysis, based on Positive and Negative Syndrome Scale (PANSS) negative and distress symptom dimensions, and whether subgrouping was informative regarding other facets of behavior and brain function. PANSS data, and other assessments, were available for 549 people with schizophrenia diagnoses. Negative and distress symptom composite scores were used as indicators in 2-step cluster analyses, which divided the sample into low symptom (n = 301), distress (n = 121), and deficit (n = 127) subgroups. Relative to the low-symptom group, the deficit and distress subgroups had comparably higher total PANSS symptoms (Ps < .001) and were similarly functionally impaired (eg, global functioning [GAF] Ps < .001), but showed markedly different patterns on symptom, cognitive and personality variables, among others. Initial analyses of functional magnetic resonance imaging (fMRI) data from a 182-participant subset of the full sample also suggested distinct patterns of neural recruitment during working memory. The field seeks more neuroscience-based systems for classifying psychiatric conditions, but these are inescapably behavioral disorders. More effective parsing of clinical and behavioral traits could identify homogeneous target groups for further neural system and molecular studies, helping to integrate clinical and neuroscience approaches.