A (Sub)field Guide to Quality Control in Hippocampal Subfield Segmentation on Highresolution T2-weighted MRI

Inquiries into properties of brain structure and function have progressed due to developments in magnetic resonance imaging (MRI). To sustain progress in investigating and quantifying neuroanatomical details in vivo, the reliability and validity of brain measurements are paramount. Quality control (QC) is a set of procedures for mitigating errors and ensuring the validity and reliability of brain measurements. Despite its importance, there is little guidance on best QC practices and reporting procedures. The study of hippocampal subfields in vivo is a critical case for QC because of their small size, inter-dependent boundary definitions, and common artifacts in the MRI data used for subfield measurements. We addressed this gap by surveying the broader scientific community studying hippocampal subfields on their views and approaches to QC. We received responses from 37 investigators spanning 10 countries, covering different career stages, and studying both healthy and pathological development and aging. In this sample, 81% of researchers considered QC to be very important or important, and 19% viewed it as fairly important. Despite this, only 46% of researchers reported on their QC processes in prior publications. In many instances, lack of reporting appeared due to ambiguous guidance on relevant details and guidance for reporting, rather than absence of QC. Here, we provide recommendations for correcting errors to maximize reliability and minimize bias. We also summarize threats to segmentation accuracy, review common QC methods, and make recommendations for best practices and reporting in publications. Implementing the recommended QC practices will collectively improve inferences to the larger population, as well as have implications for clinical practice and public health.

Widespread white matter microstructural differences in schizophrenia across 4322 individuals: results from the ENIGMA Schizophrenia DTI Working Group

The regional distribution of white matter (WM) abnormalities in schizophrenia remains poorly understood, and reported disease effects on the brain vary widely between studies. In an effort to identify commonalities across studies, we perform what we believe is the first ever large-scale coordinated study of WM microstructural differences in schizophrenia. Our analysis consisted of 2359 healthy controls and 1963 schizophrenia patients from 29 independent international studies; we harmonized the processing and statistical analyses of diffusion tensor imaging (DTI) data across sites and meta-analyzed effects across studies. Significant reductions in fractional anisotropy (FA) in schizophrenia patients were widespread, and detected in 20 of 25 regions of interest within a WM skeleton representing all major WM fasciculi. Effect sizes varied by region, peaking at (d=0.42) for the entire WM skeleton, driven more by peripheral areas as opposed to the core WM where regions of interest were defined. The anterior corona radiata (d=0.40) and corpus callosum (d=0.39), specifically its body (d=0.39) and genu (d=0.37), showed greatest effects. Significant decreases, to lesser degrees, were observed in almost all regions analyzed. Larger effect sizes were observed for FA than diffusivity measures; significantly higher mean and radial diffusivity was observed for schizophrenia patients compared with controls. No significant effects of age at onset of schizophrenia or medication dosage were detected. As the largest coordinated analysis of WM differences in a psychiatric disorder to date, the present study provides a robust profile of widespread WM abnormalities in schizophrenia patients worldwide. Interactive three-dimensional visualization of the results is available at www.enigma-viewer.org.

A multi-attribute utility instrument suitable for use in individuals with psychosis – the AQoL-4D: Findings from the Second Australian National Survey of Psychosis

Introduction

Multi-attribute utility instruments (MAUIs) are generic health-related quality of life (HRQoL) measures that enable valuation of health states relative to death (0.0) and full health (1.0). The usefulness of MAUIs in people with psychosis has been questioned, with the EQ-5D considered “insensitive”, the 15D “problematic” and the SF-6D “unsuitable”.

Objectives

Confirm the Assessment of Quality of Life (AQoL)-4D MAUI is useful and meaningful in people with psychosis.

Aims

Assess utility values across demographic, general and disease-specific health categorisations for a large nationally-representative sample with psychosis (n = 1825).

Methods

Participants underwent a comprehensive 32 module interview encompassing psychopathology to service use. Utility values were calculated by applying a standard algorithm to responses to each of 12 items of the AQoL-4D.

Results

Utility values were assessed for 1793 participants (98.2%). No ceiling effect was observed and only 6.6% of participants scored in the top decile of HRQoL [0.9–10.0]. In contrast, 10.8% scored in the lowest decile [−0.04–0.10], a floor effect observed in 0.4%. The mean utility value was 0.49 (95% CI: 0.48–0.51), significantly lower than the Australian population norm of 0.81 (95% CI: 0.81–0.82). Greatest impacts on HRQoL were for diminishing global independent functioning as measured by the MSIF (ESMSIF: 0.68–2.24), self-rated current mental health (ESMH: 0.15–1.65) and physical health status (ESPH: 0.11–1.21). Strong effects also observed for course of disorder (ESCoD: 0.08–1.13), current suicidal ideation (ESCSI1: 0.76–1.08), and labor force participation (ESLFP: 0.11–0.97).

Conclusions

The AQoL-4D had good lower end sensitivity in a large sample of people with a psychotic illness, and demonstrated responsiveness across subjective, objective and symptom measures.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Psychosis prevalence and physical, metabolic and cognitive co-morbidity: data from the second Australian national survey of psychosis

BACKGROUND

There are insufficient data from nationwide surveys on the prevalence of specific psychotic disorders and associated co-morbidities.

METHOD

The 2010 Australian national psychosis survey used a two-phase design to draw a representative sample of adults aged 18-64 years with psychotic disorders in contact with public treatment services from an estimated resident population of 1 464 923 adults. This paper is based on data from 1642 participants with an International Classification of Diseases (ICD)-10 psychotic disorder. Its aim is to present estimates of treated prevalence and lifetime morbid risk of psychosis, and to describe the cognitive, physical health and substance use profiles of participants.

RESULTS

The 1-month treated prevalence of psychotic disorders was 3.10 cases per 1000 population aged 18-64 years, not accounting for people solely accessing primary care services; lifetime morbid risk was 3.45 per 1000. Mean premorbid intelligence quotient was approximately 0.5 s.d.s below the population mean; current cognitive ability (measured with a digit symbol coding task) was 1.6 s.d.s below the population mean. For both cognitive tests, higher scores were significantly associated with better independent functioning. The prevalence of the metabolic syndrome was high, affecting 60.8% of participants, and pervasive across diagnostic groups. Of the participants, two-thirds (65.9%) were current smokers, 47.4% were obese and 32.4% were sedentary. Of the participants, half (49.8%) had a lifetime history of alcohol abuse/dependence and 50.8% lifetime cannabis abuse/dependence.

CONCLUSIONS

Our findings highlight the need for comprehensive, integrative models of recovery to maximize the potential for good health and quality of life for people with psychotic illness.

Providing nicotine dependence treatment to psychiatric inpatients: the views of Australian nurse managers

The prevalence of smoking in psychiatric settings remains high. This study aims to describe the views of nurse managers in psychiatric inpatient settings regarding the provision of nicotine dependence treatment, and whether there were associations between such views and the provision of nicotine dependence treatment. A cross-sectional survey was mailed to all public psychiatric inpatient units in New South Wales, Australia, for completion by nurse managers. Of the identified 131 service units, 123 completed questionnaires were returned (94%). Patient-related factors were considered to have a high level of influence on the provision of nicotine dependence treatment: patients requesting assistance to quit (58%), patients being receptive to interventions (52%), and patient health improving with quitting (45%). Units where the respondent reported that nicotine dependence treatment was as important as other roles were more likely to provide nicotine dependence treatment compared to units whose respondents did not hold this view (OR = 0.257, d.f. = 1, P < 0.01). While the results indicate strong support for the provision of nicotine dependence treatment, this support appears qualified by perceived patient readiness to quit, suggesting care is provided selectively rather than systematically. Positioning smoking as an addiction requiring treatment within a traditional curative approach may lead to a health service more conducive to the routine provision of nicotine dependence treatment.

The diagnostic interview for psychoses (DIP): development, reliability and applications

BACKGROUND

We describe the development, reliability and applications of the Diagnostic Interview for Psychoses (DIP), a comprehensive interview schedule for psychotic disorders.

METHOD

The DIP is intended for use by interviewers with a clinical background and was designed to occupy the middle ground between fully structured, lay-administered schedules, and semi-structured, psychiatrist-administered interviews. It encompasses four main domains: (a) demographic data; (b) social functioning and disability; (c) a diagnostic module comprising symptoms, signs and past history ratings; and (d) patterns of service utilization and patient-perceived need for services. It generates diagnoses according to several sets of criteria using the OPCRIT computerized diagnostic algorithm and can be administered either on-screen or in a hard-copy format.

RESULTS

The DIP proved easy to use and was well accepted in the field. For the diagnostic module, inter-rater reliability was assessed on 20 cases rated by 24 clinicians: good reliability was demonstrated for both ICD-10 and DSM-III-R diagnoses. Seven cases were interviewed 2-11 weeks apart to determine test-retest reliability, with pairwise agreement of 0.8-1.0 for most items. Diagnostic validity was assessed in 10 cases, interviewed with the DIP and using the SCAN as 'gold standard': in nine cases clinical diagnoses were in agreement.

CONCLUSIONS

The DIP is suitable for use in large-scale epidemiological studies of psychotic disorders, as well as in smaller studies where time is at a premium. While the diagnostic module stands on its own, the full DIP schedule, covering demography, social functioning and service utilization makes it a versatile multi-purpose tool.

Analysis of the repertoire of cattle CD4(+) T cells reactive with bovine viral diarrhoea virus

Cell-mediated immunity and CD4(+) cells in particular are important for the resolution of acute infection with non-cytopathic bovine viral diarrhoea virus (BVDV). CD4(+) T cells were shown to recognise virus-infected and non-infectious-protein-pulsed APCs, whereas CD8(+) T cells recognised only virus-infected APCs. T cell recognition was strain cross-reactive and MHC-restricted. Using native and recombinant antigens, we identified the structural glycoprotein E2 and the non-structural protein NS3 as dominant CD4(+) T cell determinants. The repertoire of CD4(+) T cell responses to E2 and NS3 was examined using inbred, homozygous cattle and overlapping synthetic peptides. The repertoire was biased toward conserved regions of NS3 and excluded the hypervariable regions of E2. The number of peptides that were recognised varied between animals but patterns could be distinguished in those animals that shared the same DRB3(*) allele. Of particular interest were: (i) a determinant that was recognised in the context of both DRB3(*) alleles (i.e. DRB3(*)2002 and DRB3(*)0701), (ii) two determinants that were juxtaposed to B cell sites, and (iii) a determinant that had structural analogy with a NS3 epitope previously described for the closely related hepatitis C virus. The minimum stimulatory sequence of the latter, NS3(397-414), was located to residues NS3(400-410).

A risk factor screening and assessment protocol for schizophrenia and related psychosis

OBJECTIVE

The Psychological Assistance Service (PAS) opened in Newcastle, New South Wales in 1997 as a clinical service for the assessment and treatment of young people at high risk of psychosis and those experiencing a first psychotic episode. The aim of this paper is to describe the assessment protocol of PAS, which is strongly influenced by the neurodevelopmental perspective on early onset psychosis.

METHOD

The systematic assessment of patients referred to PAS using a protocol over a 2 week period is described. The protocol includes a narrative history, structured diagnostic interview, quantitative assessment of symptoms and other clinical features, a neurological examination and comprehensive neuropsychological test battery.

RESULTS

The clinic has received over 250 referrals in a 2 year period and accepted 116 patients for a full assessment, of whom 60 were deemed to be 'at-risk' of psychosis and 56 were experiencing their first psychotic episode. Both groups were similar with respect to gender and there were minor age differences. The first-episode group experienced more reality distortion, schizotypal and negative symptoms. While both groups showed some neuropsychological and neurological impairment, there were no statistically significant differences between the groups on these variables except for a test of executive functioning in which the first-episode group was more impaired than the 'at-risk' group. A low rate of conversion to psychosis occurred in the 'at-risk' group.

CONCLUSIONS

The minor differences between the two groups may have been related to relatively small sample sizes, although some similarities between the groups were to be expected. The low rate of conversion to psychosis in the 'at-risk' group is discussed. Further analyses using larger samples are necessary to determine the validity of the various 'at-risk' categories and this will involve following a sufficiently large sample over an adequate time. The most efficient way of doing this would be to pool data across centres with comparable early intervention programs.

Psychotic disorders in urban areas: an overview of the Study on Low Prevalence Disorders

OBJECTIVE

This paper reports on a study designed within the framework of the National Survey of Mental Health and Wellbeing to: estimate the prevalence of psychoses in urban areas of Australia; identify profiles of symptomatology, impairments and disabilities; collect information on services received and needed; and explore quality of life issues in a broadly representative sample of people with psychotic illnesses.

METHOD

The study was conducted over four areas in the Australian Capital Territory, Queensland, Victoria and Western Australia, as a two-phase survey: (i) a census and screening for psychosis of all individuals who made contacts with mental health services during a period of 1 month in 1997; and (ii) interviews with a stratified random sample (n=980) of the screen-positive individuals (n=3800) using a standardised instrument.

RESULTS

The point prevalence (1 month) of psychotic disorders in the urban population aged 18-64 is in the range of 4-7 per 1000 with a weighted mean of 4.7 per 1000. People with psychotic disorders experience high rates of functional impairments and disability, decreased quality of life, persistent symptoms, substance-use comorbidity and frequent side effects of medication. Although the utilisation of hospital-based and community mental health services, as well as of public and non-governmental helping agencies, is high, the majority live in extreme social isolation and adverse socioeconomic circumstances. Among the many unmet needs, the limited availability of community-based rehabilitation, supported accommodation and employment opportunities is particularly prominent.

CONCLUSIONS

The so-called 'low-prevalence' psychotic disorders represent a major and complex public health problem, associated with heavy personal and social costs. There is a need for a broad programmatic approach, involving various sectors of the community, to tackle the multiple dimensions of clinical disorder, personal functioning and socioeconomic environment that influence the course and outcome of psychosis and ultimately determine the effectiveness of service-based intervention.

Changes in ego defenses with recovery from depression

This study aimed to determine whether patterns of ego defense change with short-term treatment of psychiatric illness. The subjects were 37 inpatients and outpatients with a DSM-III-R diagnosis of major depressive disorder being treated using standard clinical methods. Ego defenses before and 7 to 9 weeks after commencement of treatment were measured using a shortened version of the Defense Style Questionnaire. There was a significant decline in the use of immature defenses with symptomatic recovery, but no change in the neurotic or mature defenses. Patients with additional axis I diagnoses and/or abnormal personality traits (N = 15) used more neurotic defenses than their counterparts with major depression alone (N = 22), but this pattern did not change with time. The study demonstrates the short-term mutability of immature defenses in relation to an episode of psychiatric illness and provides empirical support for the concept of temporary regression in the context of psychiatric illness episodes.

The effect of illness duration on perceptual asymmetry in schizophrenia

Perceptual asymmetry in a group of schizophrenic subjects who were clinically stable and living in the community was compared with a group of normal control subjects matched for age and sex using a dichotic monitoring task of language processing. Schizophrenic subjects showed reduced target detection and slower reaction times for both left and right ear inputs. In relation to performance asymmetry, the schizophrenic subjects had a reduced speed of responding to left ear items compared to normal controls. Within the schizophrenic group differences in performance emerged according to duration of illness. Shorter duration of illness was associated with poorer target detection overall and comparatively greater magnitude of the normal right ear advantage. The latter was accounted for by a relative augmentation of the normal left ear performance decrement. These results were partly reflected in the reaction time measures. The findings suggest that as illness duration increases there may be a tendency for certain aspects of the information processing abnormality in schizophrenia to normalise, in spite of continued deficits as reflected in prolonged reaction times.

AuthorBase: a database of authoring systems software

A working prototype database of authoring system software was developed as part of a study of authoring software conducted by the National Library of Medicine. The database and development issues ranging from the scope of the database to what information to document are described. The protype demonstrates that records of reasonable integrity can be derived from vendor supplied information as long as users understand the database is only an initial starting point in searching for authoring software and a resource for becoming generally familiar with the technology.

Differences in dichotic listening asymmetries in depression according to symptomatology

Subjects suffering from major depressive disorder were compared to normal controls on two verbal dichotic listening tasks. Although there were no significant differences between the groups on a task primarily of language perception, significant differences were obtained on a task with an attentional component. Overall performance was lower for the depressed group and ear asymmetry was reduced. Within the depressed group ear asymmetry varied according to symptomatology; withdrawal-retardation was associated with a lack of asymmetry and anxiety with a normal right ear advantage. The results were interpreted in terms of an interaction between affect and attention, and possible underlying mechanisms of cerebral hemisphere function were discussed.

The effects of antipsychotic drugs and symptomatology on perceptual asymmetry in schizophrenia

Perceptual asymmetry was measured in acutely psychotic schizophrenic patients and normal controls using a dichotic monitoring task. Although the schizophrenic group differed from the controls in terms of accuracy and speed of response, there were no significant group differences with respect to asymmetries in these variables. The pattern of responding in the schizophrenic group was also examined in relation to differences in symptomatology and antipsychotic drug administration. These variables, in isolation and in interaction with each other, were found to have a number of effects on both asymmetry and overall level of responding. The results were interpreted in the context of an information processing model of functional hemisphere asymmetry in schizophrenia, and the implications regarding the nature of schizophrenic symptomatology and the effects of antipsychotic drugs were discussed.

Patients' techniques for coping with schizophrenia: an exploratory study

Non-hospitalized schizophrenic patients were administered a questionnaire designed to assess how they coped with various symptoms of their illness. Of the 200 subjects in the sample, 92 gave additional descriptions of coping techniques which they found useful in addition to those listed in the questionnaire. This report presents the latter findings and categorizes the range of coping techniques described. Patients used a variety of such techniques ranging across a spectrum of behaviour change, socialization, cognitive control and use of medical care as well as behaviours which were likely to have been identified by others as symptomatic of the illness.

The dexamethasone suppression test in relation to symptomatology: preliminary findings controlling for serum dexamethasone concentrations

A diagnostically heterogeneous sample of psychiatric inpatients (n = 52) was administered the 1 mg dexamethasone suppression test (DST) shortly after hospital admission. Each was also assessed using the Hamilton Rating Scale for Depression (HRSD) and selected items of the Present State Examination (PSE) representing psychomotor retardation and anxiety. A potent determinant of postdexamethasone serum cortisol concentrations was found to be the level of serum dexamethasone concentration achieved following the oral dose. No relationship was found between postdexamethasone cortisol concentration and the scores on either the HRSD or an anxiety scale derived from selected PSE items. However, symptoms of psychomotor retardation were significantly related to postdexamethasone serum cortisol concentration, particularly when the serum dexamethasone concentrations were taken into account. It may be that DST nonsuppression in psychiatric patients is in part a reflection of the presence of psychomotor retardation, a phenomenon that cuts across diagnostic categories.

Dichotic listening asymmetries and psychotic symptoms in schizophrenia: a preliminary report

Schizophrenic subjects were compared with both psychiatric control and normal control groups on two verbal measures of functional hemispheric asymmetry on a dichotic listening task. One measure of language perception showed little variation in ear differences across groups. However, the task that contained both attentional and language-processing components showed variations in asymmetry according to symptomatology. Subjects with high scores on scales of hallucinations and delusions showed a pattern of ear differences that was not found in those with low scores on these symptom dimensions. The results may reflect cognitive factors in a dysfunctional information-processing system and, in particular, attentional disturbance rather than anomalies in the lateralization of language.

Urinary MHPG, platelet 3H-imipramine binding and symptomatology in depression: an exploratory study of clinical heterogeneity

Urinary MHPG concentrations and platelet 3H-imipramine binding (Bmax, Kd) were measured in 20 psychiatric inpatients with diagnoses of major depressive disorder. Clinical assessments were performed using the Present State Examination (PSE) interview, and several dimensions of symptomatology were constructed on the basis of the PSE items. There was a significant positive relationship between Bmax and items reflecting both psychomotor retardation and anxiety. Urinary MHPG bore a comparatively complex nonlinear relationship to Bmax and to the psychomotor retardation symptom dimension. Urinary MHPG also showed an inverse, curvilinear correlation with certain neurotic symptoms. The implications of these findings are briefly discussed in the light of the "dysregulation" hypothesis of affective disorder.

The effect of serum dexamethasone concentrations in the dexamethasone suppression test

Serum dexamethasone and cortisol concentrations were measured in a sample of 98 psychiatric inpatients during the course of the 1-mg oral overnight Dexamethasone Suppression Test (DST). Suppressors were found to have significantly higher serum dexamethasone concentrations than nonsuppressors at each time of sampling (8:00 AM, 4:00 PM, and 11:00 PM). There was a significant inverse curvilinear relationship between serum dexamethasone and cortisol concentrations at each sample time. Although serum dexamethasone concentration was a potent determinant of postdexamethasone serum cortisol concentration, there were still significantly higher serum concentrations of cortisol in patients with major depression compared with patients with other disorders when dexamethasone concentrations were statistically controlled. By taking serum dexamethasone concentrations into account in defining DST suppression status, a modest increase in diagnostic specificity was achieved, but no substantial change in sensitivity.

Schizophrenia: an information processing model

There is a wealth of literature associating schizophrenia with disorders of information processing and attention. This paper draws together knowledge from experimental cognitive psychology and examines how both research findings and the clinical manifestations of schizophrenia can be accommodated by an information processing paradigm. An attentional model of schizophrenia is proposed in which disorders in the perception of information are related to dysfunction at the level of preattentive processes. This is seen as one crucial difference between schizophrenia and bipolar disorder, both of which demonstrate failures of sensory gating and filter mechanisms in the acquisition and processing of inputs. Commonalities between the two disorders are thus addressed. Certain psychopathological phenomena in schizophrenia, particularly negative symptoms ('inhibition'), hallucinations and delusions, are seen as compensatory operations of a disordered information processing system. The model has heuristic value and is able to account for, and coherently organise, the variability which continues to confound research in schizophrenia.

Dexamethasone concentrations and the dexamethasone suppression test in psychiatric disorders

The dexamethasone suppression test (DST) has been widely used in psychiatry as a laboratory aid for the diagnosis of endogenous depression; failure to suppress serum cortisol levels is interpreted as confirming a clinical diagnosis of endogenous depression. We found that serum dexamethasone concentrations in this test vary widely and are determinants of the DST response: non-suppression of serum cortisol levels is associated with low serum dexamethasone concentrations, and suppression is associated with high concentrations.

Assessment of depression by questionnaire compared to DSM-III diagnosis

The LPD, a self-report questionnaire which provides a quantitative and qualitative measure of depression, was examined in relation to a criterion-based system of diagnosis, the DSM-III. Results from 190 psychiatric inpatients suggest that the LPD distinguishes depressive from non-depressive syndromes in terms of severity of depression and that patients with melancholic major depression are more severely depressed than those with non-melancholic major depression. Furthermore, major depression with melancholia and major depression without melancholia, both conform to the LPD profile of endogenous depression whereas other depressive syndromes do not. A comparison of the two systems of categorizing depression also suggests that the LPD is a relatively sensitive predictor of the diagnosis of major depressive disorder.

The use of ECT for mania in childhood bipolar disorder

A case of childhood bipolar disorder, manic type, is presented in which electroconvulsive therapy was used for the acute manic episode. The pharmacological complications which led to this choice of treatment and the computerized tomography finding of ventricular enlargement, are discussed.

Individual psychotherapy and schizophrenia

Conceptual issues in approaching the role of psychotherapy in the treatment of schizophrenic patients are discussed in the context of trainee supervision. Eight important variables which require consideration in conducting and evaluating the psychotherapy of these patients are elucidated. It is suggested that psychotherapy variables are conceptually distinct from those which belong to the frame of reference of the disease model or syndrome diagnosis, and thus demand separate attention.

The state concept and inpatient psychotherapy

A state model for categorizing psychopathology within psychotic disorders is used to describe change during the course of treatment in a single case. A preliminary assessment of the reliability of this model suggests that with further refinement it may be usefully applied to both ward behavior and psychotherapy material. The psychotherapeutic and research implications of the model are also discussed.