Naturalistic Clinical Setting Research Articles

Effect of long-acting antipsychotic treatment on psychiatric hospitalization rate in early psychosis patients: a naturalistic study.

The effectiveness of long-acting injectable (LAI) antipsychotics in preventing relapses of first-episode psychosis is currently debated. The study aimed to investigate the number of psychiatric hospitalizations comparing the LAI cohort versus the oral cohort during different phases of the illness, pre-LAI treatment, during LAI treatment, and after LAI treatment. A naturalistic study was conducted on two independent cohorts of early psychosis patients receiving treatment from a specific early intervention service. The first cohort comprised 228 patients who received LAIs, while the second cohort comprised 667 patients who had never received LAIs. This study was designed as a longitudinal observational study conducted within a naturalistic clinical setting in two cohorts of early psychosis patients. Repeated series ANCOVA (ANCOVA-r) was used to study the number of hospitalizations in the different study periods (T1 = from the date of the first psychiatric record to the beginning of the mirror period; T2 = the mirror period; T3 = from the LAI implementation to the LAI discontinuation; and T4 = from the LAI discontinuation to the end). In all cases, discontinuation of LAI involved the return to oral treatment. In all, 35 patients had not T4 as they were still on LAI treatment at the time of database closing (September 2020), and their data were not included in the analysis of the effect of the LAI discontinuation. The patients in the LAI cohort were younger, more frequently males, presented more schizophrenia diagnoses, and had a higher number of hospitalizations (2.50 ± 2.61 versus 1.19 ± 1.69; p < 0.001) than the oral cohort. The number of hospitalizations at the end of the follow-up was higher in the LAI cohort [0.20 (standard deviation (SD)) = 0.79] versus 0.45 [SD = 0.45 (SD = 1.13); F(23.90), p < 0.001]. However, after the introduction of LAIs, the differences in hospitalization rates between the two cohorts became less pronounced. Once LAI treatment was ceased, the hospitalization rate increased again. In our study, early psychosis patients receiving LAIs experienced a greater decrease in hospitalizations after introducing the LAI treatment than those treated solely with oral medication. These findings support using LAIs as a viable strategy for preventing rehospitalization and improving the overall course of treatment for individuals with early psychosis.

Cognitive-Behavioral Therapy for Complicated Grief Reactions: Treatment Protocol and Preliminary Findings From a Naturalistic Setting

In bereavement, some individuals develop complicated grief reactions (CGR), including symptoms of prolonged grief disorder (PGD), posttraumatic stress disorder (PTSD), and depression. Symptoms of PGD often co-occur with other complicated grief reactions, e.g., PTSD and depression, pointing to the need for a transdiagnostic understanding of CGR to inform treatment. In this paper, a transdiagnostic cognitive-behavioral therapy for CGR called “CBTgrief” is explained, including its theoretical framework and treatment content. CBTgrief is based on previous cognitive-behavioral conceptualizations of PGD, PTSD, and depression and includes 12 sessions consisting of exposure, cognitive restructuring, and behavioral activation. Preliminary findings of CBTgrief are evaluated in terms of feasibility, acceptability, and treatment satisfaction in a sample of eight older bereaved individuals treated for different types of CGR in a naturalistic clinical setting. Additionally, theory-driven hypotheses about changes in CGR and theoretical proposed core maintaining processes are evaluated using Bayesian informative hypotheses testing. Preliminary findings, limitations, implications, and future directions are discussed.

Racial disparities in cancer genetic counseling encounters: study protocol for investigating patient-genetic counselor communication in the naturalistic clinical setting using a convergent mixed methods design

BackgroundDespite decades of effort to reduce racial cancer disparities, Black people continue to die at higher rates from cancer than any other U.S. racial group. Because prevention is a key to the cost-effective and long-term control of cancer, the potential for cancer genetic counseling to play a central role in reducing racial cancer disparities is high. However, the benefits of genetic counseling are not equitable across race. Only 2% of genetic counselors self-identify as Black/African American, so most genetic counseling encounters with Black patients are racially discordant. Patients in racially discordant medical interactions tend to have poorer quality patient-provider communication and receive suboptimal clinical recommendations. One major factor that contributes to these healthcare disparities is racial bias. Drawing on findings from prior research, we hypothesize that genetic counselor providers’ implicit racial prejudice will be associated negatively with the quality of patient-provider communication, while providers’ explicit negative racial stereotypes will be associated negatively with the comprehensiveness of clinical discussions of cancer risk and genetic testing for Black (vs. White) patients.MethodsUsing a convergent mixed methods research design, we will collect data from at least 15 genetic counseling providers, from two different institutions, and their 220 patients (approximately equal number of Black and White patients per provider) whose appointments are for a hereditary cancer condition. The data sources will include two provider surveys, two patient surveys, video- and/or audio-recordings of genetic counseling encounters, and medical chart reviews. The recorded cancer genetic counseling in-person and telehealth encounters will be analyzed both qualitatively and quantitatively to assess the quality of patient-provider communication and the comprehensiveness of clinical discussion. Those data will be linked to pre- and post-encounter survey data and data from medical chart reviews to test our hypotheses.DiscussionFindings from this multi-site study will highlight specific aspects of cancer genetic counseling encounters (patient-provider communication and clinical recommendations) that are directly associated with patient-centered outcomes (e.g., satisfaction, trust, genetic testing completion). Patient-provider communication and clinical recommendations are modifiable factors that can be integrated into current genetic counseling training curricula and thus can have immediate impact on genetic counseling training and practice.

Validation of the test for finding word retrieval deficits (WoFi) in detecting Alzheimer's disease in a naturalistic clinical setting

BackgroundDetecting impaired naming capacity contributes to the detection of mild (MildND) and major (MajorND) neurocognitive disorder due to Alzheimer’s disease (AD). The Test for Finding Word retrieval deficits (WoFi) is a new, 50-item, auditory stimuli-based instrument.ObjectiveThe study aimed to adapt WoFi to the Greek language, to develop a short version of WoFi (WoFi-brief), to compare the item frequency and the utility of both instruments with the naming subtest of the widely used Addenbrooke’s cognitive examination III (ACEIIINaming) in detecting MildND and MajorND due to AD.MethodsThis cross-sectional, validation study included 99 individuals without neurocognitive disorder, as well as 114 and 49 patients with MildND and MajorND due to AD, respectively. The analyses included categorical principal components analysis using Cramer’s V, assessment of the frequency of test items based on corpora of television subtitles, comparison analyses, Kernel Fisher discriminant analysis models, proportional odds logistic regression (POLR) models and stratified repeated random subsampling used to recursive partitioning to training and validation set (70/30 ratio).ResultsWoFi and WoFi-brief, which consists of 16 items, have comparable item frequency and utility and outperform ACEIIINaming. According to the results of the discriminant analysis, the misclassification error was 30.9%, 33.6% and 42.4% for WoFi, WoFi-brief and ACEIIINaming, respectively. In the validation regression model including WoFi the mean misclassification error was 33%, while in those including WoFi-brief and ACEIIINaming it was 31% and 34%, respectively.ConclusionsWoFi and WoFi-brief are more effective in detecting MildND and MajorND due to AD than ACEIIINaming.

Dialectical behaviour therapy for posttraumatic stress disorder (DBT-PTSD): transportability to everyday clinical care in a residential mental health centre

ABSTRACT Background: Dialectical Behaviour Therapy for Posttraumatic Stress Disorder (DBT-PTSD) is a phase-based treatment for PTSD. The DBT-PTSD treatment programme’s efficacy has not been tested during standard operation, outside of laboratory outcome studies. Objective: The present pilot study investigated the transportability of the DBT-PTSD treatment to a real word clinical setting in a residential mental health centre. Methods: The DBT-PTSD treatment was compared to a treatment as usual (TAU) condition in a non-randomized study. Overall, 156 patients from a residential mental health centre were included. Propensity score matching was used to match participants in the two treatment arms based on baseline characteristics. Primary and secondary outcomes (PTSD and other symptoms) were assessed at the time of admission and at the time of discharge. Results: The DBT-PTSD treatment outperformed the TAU condition in the improvement of all primary outcomes, as indicated by a significant time and group interaction. There were notable differences in the effect sizes between the unmatched and matched sample as well as between the available and the intent-to-treat (ITT) data analyses. The effect sizes in the ITT data analyses were much lower. Both treatment groups showed similar improvements in secondary outcomes. Conclusions: This study provides initial evidence for the transportability of the DBT-PTSD treatment to a naturalistic clinical care setting, but with considerably lower effect sizes than in previously published laboratory RCTs. The higher efficacy of DBT-PTSD compared to TAU may largely depend on patient’s adherence to treatment.

Effectiveness of Group CBT on Internalizing and Externalizing Symptoms in Children with Mixed Psychiatric Disorders.

Our study addressed the gap in research on the effectiveness of cognitive behavioral therapy (CBT) in treating children with mixed psychiatric disorders. We examined the immediate and long-term effects of group CBT (GCBT), delivered in naturalistic clinical settings, on reducing internalizing and externalizing symptoms in children with mixed psychiatric disorders. Further, we compared the effectiveness of cost-effective, manualized GCBT to treatment as usual (TAU) consisting of individually tailored psychiatric outpatient services delivered by mental health care specialists. Children aged 6-12 years (n = 103) diagnosed with psychiatric disorders, more than 70% with psychiatric comorbidity, were assigned either directly to GCBT (GCBT group; n = 52) or TAU for approximately 3 months, after which they received GCBT (TAU + GCBT group; n = 51). Internalizing and externalizing symptoms were assessed using parent- and teacher-report questionnaires (Child Behavior Checklist and Teacher Report Form) at referral to treatment, pre-treatment, post-treatment, and six-month follow-up. Parent- and teacher-rated internalizing symptoms and parent-rated externalizing symptoms were reduced immediately after GCBT. Long-term GCBT gains were prominent for parent-rated externalizing symptoms. No differences were observed between the effectiveness of GCBT and TAU. Our results suggest that GCBT and TAU services are equally effective in treating internalizing and externalizing symptoms in children with mixed psychiatric disorders, providing support for the broader use of cost-effective manualized GCBT. Manualized GCBT, which requires relatively short training, can also be delivered at primary healthcare levels. Our results are of relevance to cost-effectiveness and global mental health staff shortages.

The increased inter-brain neural synchronization in prefrontal cortex between simulated patient and acupuncturist during acupuncture stimulation: Evidence from functional near-infrared spectroscopy hyperscanning.

The patient-acupuncturist interaction was a critical influencing factor for acupuncture effects but its mechanism remains unclear. This study aimed to examine the inter-brain mechanism of patient-acupuncturist dyad during acupuncture stimulation in a naturalistic clinical setting. Seventy healthy subjects (simulated "patients") were randomly assigned to two groups and received verum acupuncture group or sham acupuncture by one acupuncturist. Functional near-infrared spectroscopy hyperscanning was used to simultaneously record the neural responses of "patient"-acupuncturist dyad during acupuncture stimulation in each group. The results showed that inter-brain neural synchronization (INS) in the prefrontal cortex (PFC) of "patient"-acupuncturist dyad was significantly increased during verum but not sham acupuncture stimuli, and positively correlated with the needling sensations of "patients." Granger causality analysis demonstrated that there were no significant differences in INS direction between the "patient" and the acupuncturist. This study identified the increase of INS between "patient" and acupuncturist, and suggested that PFC was important to the interaction of "patient"-acupuncturist dyad.

Asian Subgroup Analysis of the REMISSIO Study: A Long-Term Efficacy and Safety Study of Paliperidone Palmitate 3-month Formulation in Patients with Stable Schizophrenia in a Naturalistic Clinical Setting.

ObjectiveTo evaluate the long-term efficacy and safety of three-monthly paliperidone palmitate (PP3M) in Asian patients with stable schizophrenia in a naturalistic setting.MethodsAsian patients recruited between May 2016 and March 2018 from the prospective, single-arm, non-randomized, open-label, multi-national REMISSIO study were analyzed. Patients received PP3M over 12 months following ≥ 4 months of treatment with one-monthly paliperidone palmitate. The primary efficacy endpoint was the proportion of patients who achieved symptomatic remission. Other endpoints were changes in Positive and Negative Syndrome Scale (PANSS) and Personal and Social Performance (PSP) total scores, hospitalization rates, and safety.ResultsA total of 71 patients (23.3%) were Asian (South Korea 33, Malaysia 21, Taiwan 17); 95.8% of patients completed the study. At LOCF, 71% of Asian patients achieved symptomatic remission compared to the overall population (n = 172/303, 56.8%). Improvements in mean (standard deviation) PANSS and PSP total scores from baseline to LOCF in Asian patients and overall population were clinically significant. A lower proportion of Asian patients had ≥ 1 psychiatric hospitalization after PP3M treatment (n = 1/70, 1.4%) than during the 12 months before (n = 12/70, 17.1%); compared with patients in the overall population after (n = 8/303, 2.6%) and before PP3M treatment (n = 37/303, 12.2%). The overall incidence of treatment-emergent adverse events across Asian patients was 62.9% compared to 53.1% in the overall population. Safety findings were consistent with the known safety profile of PP3M.ConclusionOur findings confirm existing evidence on the efficacy and tolerability of PP3M in Asian patients with stable schizophrenia over 12 months of treatment.

Group treatment for complex dissociative disorders: a randomized clinical trial

BackgroundPatients with complex dissociative disorders (CDD) report high levels of childhood- abuse experiences, clinical comorbidity, functional impairment, and treatment utilization. Although a few naturalistic studies indicate that these patients can benefit from psychotherapy, no randomized controlled trials have been reported with this patient-group. The current study evaluates a structured protocolled group treatment delivered in a naturalistic clinical setting to patients with CDD, as an add-on to individual treatment.MethodsFifty nine patients with CDD were randomized to 20 sessions of stabilizing group–treatment, conjoint with individual therapy, or individual therapy alone, in a delayed-treatment design. The treatment was based on the manual Coping with Trauma-Related Dissociation. The primary outcome was Global Assessment of Functioning (GAF), while secondary outcomes were PTSD and dissociative symptoms, general psychopathology, and interpersonal difficulties.ResultsMixed effect models showed no condition x time interaction during the delayed treatment period, indicating no immediate differences between conditions in the primary outcome. Similar results were observed for secondary outcomes. Within-group effects were non-significant in both conditions from baseline to end of treatment, but significant improvements in psychosocial function, PTSD symptoms, and general psychopathology were observed over a 6-months follow-up period.ConclusionIn the first randomized controlled trial for the treatment of complex dissociative disorders, stabilizing group treatment did not produce immediate superior outcomes. Treatment was shown to be associated with improvements in psychological functioning.Trial registrationClinical Trials (NCT02450617).

Effectiveness and Adverse Effects of Risperidone in Children with Autism Spectrum Disorder in a Naturalistic Clinical Setting at a University Hospital in Oman.

Objective This study aimed at examining the effectiveness of treating children with autism spectrum disorder (ASD) who present with irritability, aggression, and disruptive behavior at the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman, with risperidone, and to note any sex-based differences among this cohort. Method This was a retrospective study conducted at the Department of Behavioral Medicine at SQUH over two years from January 2017 to December 2018. This study included all children aged 3 to 18 years attending the Child and Adolescent Mental Health Service (CAMHS) outpatient clinic with a diagnosis of ASD, based on the DSM-5 criteria, and comorbid disruptive behavior, who had been prescribed risperidone. Result This study identified 95 ASD patients (72 males). Male patients' BMI score after 12 months of risperidone treatment showed an increase by 0.62 (1.57 SD; P=0.001); however, there was no significant change among female patients. Somnolence was noted in 69.6% of female patients as compared to 34.7% of males (P=0.003). Among those with a family history of ASD, 5 out of 17 patients had treatment success (29.4%), whereas 70 out of 78 patients (90.0%) who did not have a similar history had successful treatment. Conclusion In conclusion, low-dose risperidone monotherapy is effective and well tolerated among some children with ASD who present with disruptive behavior in a naturalistic clinical setting. However, we found that some of the side effects, such as weight gain and somnolence, were concerning.

A Retrospective Naturalistic Study Comparing the Efficacy of Ketamine and Repetitive Transcranial Magnetic Stimulation for Treatment-Resistant Depression.

Depression is a common mental disorder that affects many people worldwide, while a significant proportion of patients remain non-responsive to antidepressant medications. Alternative treatment options such as ketamine therapy and repetitive transcranial magnetic stimulation (rTMS) therapy are offered nowadays. This study aims to describe and compare the acute antidepressive efficacy of both, intramuscular ketamine and rTMS in depression patients seeking help in a naturalistic clinical mental health setting. The clinical records of 24 patients with treatment resistant depression were collected from the clinical base of a real life clinic. Twelve patients were treated with intramuscular ketamine, twice weekly for 8 sessions, and twelve patients were treated with 30 sessions of left dorsolateral prefrontal cortex – intermittent theta-burst stimulation (DLPFC-iTBS). Using three clinical assessments (HDRS, HAM-A, BDI-II), our data reveal that both therapies led to significant improvement in symptoms from pre- to post- treatment, as well as that the two experimental groups did not differ significantly with respect to pre- to post- depressive and anxiety symptoms, indicating that the effect of both experimental groups in our sample was equally effective. Furthermore, our results showed high remission and response rates in both groups, with no statistical differences between the patients of ketamine group and rTMS group in remission and response rates. We show a significant pre- to post- treatment reduction in depressive and anxiety symptoms, with no significant differences between the two experimental groups, indicating that the effect of both therapies was equally effective in our limited sample.

Validation of the Cognitive Telephone Screening Instruments COGTEL and COGTEL+ in Identifying Clinically Diagnosed Neurocognitive Disorder Due to Alzheimer's Disease in a Naturalistic Clinical Setting.

Background: Telephone-based neurocognitive instruments embody valuable tools in identifying cognitive impairment in research settings and lately also in clinical contexts due to the pandemic crisis. The accuracy of the Cognitive Telephone Screening Instrument (COGTEL) in detecting mild- (MiND) and major (MaND) neurocognitive disorder has not been studied yet.Objective:Comparison of the utility of COGTEL and COGTEL+, which is enriched with orientation items, with the modified Mini-Mental State Examination (3MS) in detecting MiND and MaND due to Alzheimer’s disease (AD) and assessment of the impact of COGTEL face-to-face-versus telephone administration on individual performance.Methods:The study included 197 cognitively intact individuals (CI), being at least 45 years old, 95 and 65 patients with MiND and MaND due to AD, respectively. In 20 individuals COGTEL was administered both in face-to-face and telephone sessions. Statistical analyses included proportional odds logistic regression models, stratified repeated random subsampling used to recursive partitioning to training and validation set (70/30 ratio), and an appropriate F-test.Results:All studied instruments were significant predictors of diagnostic outcome, but COGTEL+ and 3MS explained more variance relative to the original COGTEL. Except for the validation regression models including COGTEL in which the average misclassification error slightly exceeded 15%, in all other cases the average misclassification errors (%) were lower than 15%. COGTEL administration modality was not related to systematic over- or underestimation of performance on COGTEL.Conclusion:COGTEL+ is a valuable instrument in detecting MiND and MaND and can be administered in face-to-face or telephone sessions.

Seizure risk with repetitive TMS: Survey results from over a half-million treatment sessions

BackgroundSeizures are rare during repetitive transcranial magnetic stimulation (rTMS) treatment, but estimating risk is difficult because of study heterogeneity and sampling limitations. Moreover, there are few studies comparing rates between device manufacturers. ObjectiveThe objective of this study was to calculate rTMS seizure rates across various FDA-cleared devices in naturalistic clinical settings. MethodsIn July and August 2018, approximately 500 members of the Clinical TMS Society (CTMSS) were electronically surveyed about seizures in their practices. Seizures were distinguished from non-seizures by a remote semi-structured interview with a Board-certified neurologist and Co-Chair of the CTMSS Standards Committee. Exact Poisson calculations were used to estimate seizure rates and confidence intervals across the four most widely used manufacturers. ResultsThe survey was completed by 134 members, with 9 responses excluded because of data inconsistencies. In total, 18 seizures were reported in 586,656 sessions and 25,526 patients across all device manufacturers. The overall seizure rate was 0.31 (95% CI: 0.18, 0.48) per 10,000 sessions, and 0.71 (95% CI: 0.42, 1.11) per 1000 patients. The Brainsway H-coil seizure rate of 5.56 per 1000 patients (95% CI: 2.77,9.95) was significantly higher (p < 0.001) than the three most widely used figure- 8 coil devices’ combined seizure rate of 0.14 per 1000 patients (95% CI: 0.01, 0.51). ConclusionThe absolute risk of a seizure with rTMS is low, but generic Brainsway H-coil treatment appears to be associated with a higher relative risk than generic figure- 8 coil treatment. Well-designed prospective studies are warranted to further investigate this risk.

Treatment Evaluation in Inpatient Psychiatry: Transdiagnostic Factors as Correlates of Treatment Outcome - Implications for Clinical Practice and for Effectiveness Research

An inpatient psychiatric-psychotherapeutic treatment was evaluated in a naturalistic setting (effectiveness research). Transdiagnostic factors were examined as correlates of treatment outcome. Self-report questionnaires were administered at the beginning and the end of the inpatient treatment. The sample (N = 378) consisted of women and men (16-80 years, M = 40.4, SD = 15.8) with primary diagnoses of depressive, anxiety or eating disorders. The average treatment duration was 8.2 weeks (SD = 3.8). Primary outcome variables were severity of symptoms and level of psychosocial functioning. As transdiagnostic correlates, self-esteem, self-efficacy, and emotion regulation were included in the regression analyses. The change in transdiagnostic factors explained a significant proportion of the treatment outcome (explained variance: 8-27 % self-efficacy, 23-42 % self-esteem, 10-26 % emotion regulation). The present study shows that the evaluation of a treatment in a naturalistic clinical setting is feasible. Transdiagnostic factors explained a substantial part of the statistical variance in treatment outcome across all disorders. Even if the present study design does not allow conclusions about causality, the results underline the relevance of transdiagnostic trainings (e. g., in emotion regulation) to improve effectiveness of treatment approaches.

Effectiveness of transdiagnostic group cognitive-behavioural therapy for anxiety disorders in a naturalistic clinical setting

ABSTRACT Objective: The present study evaluated the effectiveness of a transdiagnostic group-based cognitive-behavioural therapy (CBT) programme for treating anxiety, comorbid depression, and functional impairments in a hospital outpatient specialist anxiety disorders clinic. Method: 107 adult outpatients with a primary anxiety disorder completed an eight-session transdiagnostic group CBT program. Participants also completed self-report measures assessing general anxiety, anxiety disorder-specific symptoms, comorbid depression symptoms, and functional impairments. Data were collected at pre - and post-treatment, and at follow-up. Results: Significant pre- to post-treatment reductions were found on measures of state and trait anxiety, impairment in work and social functioning, comorbid depression, social anxiety, and worry severity. These treatment gains were maintained at follow-up. Limitations: There was no comparison control group in the present study given that it was conducted in a hospital setting. Some diagnostic groups were also underrepresented in the sample, which limits the conclusions that can be drawn about the effectiveness of the group treatment across anxiety disorders. Conclusions: The present findings provided preliminary support for the effectiveness and generalisability of an eight-session transdiagnostic group-based CBT delivered at a public health service, indicating its potential as a cost-effective and clinically efficient alternative to individual therapy or diagnosis-specific treatments for anxiety disorders. KEY POINTS What is already known about this topic: (1) Transdiagnostic group CBT is efficacious for treating anxiety disorders. (2) Very few studies to date have examined the effectiveness of transdiagnostic group CBT in naturalistic settings. (3) Few of the existing effectiveness studies have included disorder-specific and daily functioning measures, or conducted follow-up assessment. What this topic adds: (1) An eight-session transdiagnostic group CBT for anxiety disorders appears sufficient in leading to improvements in general and specific anxiety symptoms, work and social functioning, and comorbid depression for patients from a hospital outpatient clinic. (2) Treatment gains were maintained at follow-up. (3) Transdiagnostic group CBT is an effective, potentially cost- and resource-efficient, and easily accessible alternative to individual therapy or diagnosis-specific treatments in a naturalistic setting.

Effectiveness of Behaviour Therapy for Children and Adolescents with Tourette Syndrome and Chronic Tic Disorder in a Naturalistic Setting

It is unclear if the results of randomised controlled trials (RCTs) of behaviour therapy (BT) for Tourette syndrome (TS) and chronic tic disorder (CTD) can be generalised to naturalistic clinical settings and are durable long-term. In this naturalistic study, 74 young people with TS/CTD received BT at a specialist clinic. Data were collected at baseline, post-treatment, and at 3-, 6-, and 12-month follow-ups. Measures included the Yale Global Tic Severity Scale (YGTSS) and the Clinical Global Impression-Improvement scale (CGI-I), amongst others. Tic severity and tic-related impairment improved after treatment, with large within-group effect sizes. At post-treatment, 57% of the participants were classified as treatment responders according to the CGI-I. Tic severity and tic-related impairment improved further through the follow-up, with 75% treatment responders at the 12-month follow-up. BT is an effective and durable treatment for young people with TS/CTD in a naturalistic specialist clinical setting, with comparable effects to RCTs.

Effects of Psychotropics on the Microbiome in Patients With Depression and Anxiety: Considerations in a Naturalistic Clinical Setting

BackgroundThe antibacterial effects of psychotropics may be part of their pharmacological effects when treating depression. However, limited studies have focused on gut microbiota in relation to prescribed medication.MethodWe longitudinally investigated the relationship between patients’ prescribed medications and intestinal bacterial diversity in a naturalistic treatment course for patients with major depressive disorders and anxiety disorders. Patients were recruited and their stool was collected at 3 time points during their usual psychiatric treatments. Gut microbiota were analyzed using 16S rRNA gene sequencing. We examined the impact of psychotropics (i.e., antidepressants, anxiolytics, antipsychotics) on their gut microbial diversity and functions.ResultsWe collected 246 stool samples from 40 patients. Despite no differences in microbial diversity between medication groups at the baseline, over the course of treatment, phylogenic diversity whole-tree diversity decreased in patients on antipsychotics compared with patients without (P = .027), and beta diversity followed this trend. Based on a fixed-effect model, antipsychotics predicted microbial diversity; the higher doses correlated with less diversity based on the Shannon index and phylogenic diversity whole tree (estimate = −0.00254, SE = 0.000595, P < .0001; estimate = −0.02644, SE = 0.00833, P = .002, respectively). ConclusionAntipsychotics may play a role in decreasing the alpha diversity of the gut microbiome among patients with depression and anxiety, and our results indicate a relationship with medication dosage. Future studies are warranted and should consider patients’ types and doses of antipsychotics in order to further elucidate the mechanisms of gut-brain interactions in psychiatric disorders.

Associations between maladaptive personality domains and premature termination in an acute clinical setting.

Maladaptive personality has been positioned as one overarching framework with the potential to streamline conceptualization of both personality- and nonpersonality-related psychopathology. However, few studies have examined maladaptive personality in relation to (a) clinical outcomes in a naturalistic setting and (b) using measures short enough to be incorporated into standard clinical care. The goal of the current study, therefore, investigated the extent to which maladaptive personality domains-as measured by the Personality Inventory for DSM-5-Brief Form (PID-5 BF)-predicted premature treatment termination in one naturalistic clinical setting. Using a large sample (N = 2,730; 64% female) of psychiatric patients referred for treatment at a partial hospital program, we explored the associations between PID-5 BF domains and the likelihood of premature termination. Individuals who terminated treatment prematurely reported higher levels on all PID-5 BF domains, except antagonism, compared with those who successfully completed treatment. Further, elevations in the disinhibition and psychoticism domains were associated with approximately twice the odds of premature termination than normative levels, when examined in both single and multiple regression frameworks. Negative affectivity and antagonism were associated with reduced likelihood of premature termination only after controlling for elevations in other PID-5 BF domains; they showed no bivariate associations with premature termination. These results add to the literature on the clinical utility of the PID-5. Further, they suggest importance of considering personality pathology within diverse clinical populations and the use of the PID-5 BF as one easily administered screening tool that can provide important information about differential treatment response. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

S195. ROLE OF BOOSTER SESSION TRANSCRANIAL DIRECT CURRENT STIMULATION (TDCS) FOR PERSISTENT AUDITORY HALLUCINATIONS IN SCHIZOPHRENIA

BackgroundAuditory verbal hallucinations (AH), one of the hallmark symptoms, are present in 60–80% of schizophrenia (SZ) patients. 25% of patients suffering from AH in schizophrenia fail to respond to any psychotropic medication. Non-invasive brain stimulation techniques like transcranial direct current stimulation (tDCS), with cathodal electrode placement on the left temporoparietal junction (TPJ) is known to alleviate such symptoms in SZ. In this study, we describe the effects of booster tDCS after relapse of AH in patients. The pattern and effectiveness of booster treatment cycles for alleviation of AH in a naturalistic clinical setting are explored in this study.MethodsPatients with persistent AH (n=15) received an initial course (cycle) of add-on tDCS with cathode at left TPJ and anode over left dorsolateral prefrontal cortex (L-DLPFC) with 2mA current, twice-daily 20-minute sessions for 5 days with intersession interval of 3-hours. Clinical global impression- improvement scale (CGI-I) was rated at the end of the course for every patient. All the patients who were found to show response (“much improved” and “very much improved”) received repeat cycles of add-on booster tDCS after a varying duration ranging from 1–32 months from initial treatment course, due to relapse/persistence of AH. Thirteen out of fifteen patients received one booster cycle while one patient received 3 booster cycles and another received 12 booster cycles. We conducted a spearman’s rank correlation test to determine the correlation between CGI-I score rating at the end of add-on tDCS, and the duration of maintenance of improvement before relapse/ worsening of AH.ResultsSix of the fifteen patients (40%) had responded “very much improved” and nine (60%) patients had responded “much improved” to tDCS in the initial cycle. It was found that 50% of the initial “very much improved” responders (n=3) had a comparable response to tDCS after booster sessions for relapse of symptoms while 50% of patients showed “much improved” (n=2) and “minimally improved” (n=1) response in the booster sessions. Among the nine patients who showed “much improved” response from the initial cycle, one patient showed better response than initial cycle (“very much improved”) to booster session. Five patients showed “minimally changed” response in the second cycle in the booster sessions while three patients had comparable responses. The average duration of symptom free interval/ maintenance of improvement with initial cycle of tDCS was found to be 10.46± 9.23 months. The CGI improvement from the initial add-on tDCS course and the duration of the maintenance of improvement/symptom-free interval before the booster session was not found to be significantly correlated (r=0.332, p=0.226)DiscussionA reduction in hallucinations was noted with booster tDCS in patients who had responded to the initial course of add-on tDCS. Booster tDCS is a feasible option and given its cost-effectiveness and ease of administration, booster sessions of tDCS can be considered for resurgence of symptoms. Future studies are recommended in systematically exploring maintenance tDCS as an add-on treatment for persistent/recurring AVH in schizophrenia.

M148. NORMALIZATION IN REWARD PROCESSING DURING INITIAL TREATMENT MAY PREDICT LONG-TERM CLINICAL OUTCOME IN ANTIPSYCHOTIC NAïVE SCHIZOPHRENIA PATIENTS

BackgroundDecreased functional magnetic resonance (fMRI) signaling in ventral striatum during reward anticipation has been a consistent finding in unmedicated patients with schizophrenia. Antipsychotic medication may normalize this, which has been associated with improvement in psychotic symptoms. Whether this initial treatment response predict long term clinical outcome have not been examined previously. We here present unique data from a cohort of antipsychotic näive patients, who was examined before and after six weeks of antipsychotic monotherapy, and again after six years of naturalistic treatment. We hypothesized that improved reward related fMRI-signaling in striatum during initial treatment will be associated with less severe symptoms and a higher level of function after six years.MethodsAntipsychotic-naïve, first episode patients with schizophrenia and matched healthy controls were examined at three timepoints: Baseline, after six weeks and after six years. During the first six weeks, patients were treated with a D2/3 antagonist, after which they switched to a naturalistic clinical setting. At all three timepoints, fMRI was obtained while participants played a monetary rewarding game. Mean contrast signal during anticipation of salient events was extracted from predefined regions of interest in nucleus accumbens and caudatus. Additionally, symptom severity and level of function were assessed in patients. Remission after six years was defined by the Andreasen criteria.Long term changes in patients were analyzed with paired t-test. Repeated measures ANOVA was used to compare fMRI signal in patients and controls over time. Changes in fMRI signal during the first six weeks was compared between remitted and unremitted patients with students t-test. Correlations between symptom severity, level of function and fMRI signal up were analyzed with Spearman or Pearson as appropriate.ResultsLong term follow-up data on fMRI and psychopathology was obtained from 25 patients and 28 controls 6.7 (4.3–8.7) years after baseline examinations. In patients, symptomatology and level of function was improved (all p<0.001), and remission criteria was met by 12 (48%) of the patients.Repeated measures ANOVA of the extracted fMRI contrast signal at baseline and six years showed a group*time interaction in left Nucleus accumbens (F=4.8, p= 0.038) and left caudatus (F= 4.08, p=0=049). Mean contrast signal increased in patients but decreased in healthy controls.Change in contrast signal in left caudatus during the first six weeks of treatment differed between remitted and non-remitted patients (t=2.2, p=0.044). An increase in signal during initial treatment was found in patients later being in remission, which was not observed in non-remitted patients.Decreased fMRI contrast signal in left caudatus at six years follow up was associated with a higher level of negative symptoms (r=-0.44, p=0.02) and a lower level of function (r=0.45, p=0.02).DiscussionIn this long-term follow up study, half of the patients were in remission 4–8 years after their first schizophrenia diagnosis. These individuals were characterized by a normalization of reward anticipation signaling in left striatal regions during their initial treatment with a selective D2/3 antagonist. Schizophrenia is a diagnosis with a heterogeneous outcome, and prognostic biomarkers are still missing. The present results suggest that normalization in reward processing during initial antipsychotic treatment may predict remission six years later. Although these results need to be reproduced, they do support the notion, that patients responding to antipsychotic treatment are characterized by changes in striatal function, which may be predictive for long-term outcome.