Screening for PTSD and TBI in Veterans using Routine Clinical Laboratory Blood Tests.

Post-traumatic stress disorder (PTSD) is a mental disorder diagnosed by clinical interviews, self-report measures and neuropsychological testing. Traumatic brain injury (TBI) can have neuropsychiatric symptoms similar to PTSD. Diagnosing PTSD and TBI is challenging and more so for providers lacking specialized training facing time pressures in primary care and other general medical settings. Diagnosis relies heavily on patient self-report and patients frequently under-report or over-report their symptoms due to stigma or seeking compensation. We aimed to create objective diagnostic screening tests utilizing Clinical Laboratory Improvement Amendments (CLIA) blood tests available in most clinical settings. CLIA blood test results were ascertained in 475 male veterans with and without PTSD and TBI following warzone exposure in Iraq or Afghanistan. Using random forest (RF) methods, four classification models were derived to predict PTSD and TBI status. CLIA features were selected utilizing a stepwise forward variable selection RF procedure. The AUC, accuracy, sensitivity, and specificity were 0.730, 0.706, 0.659, and 0.715, respectively for differentiating PTSD and healthy controls (HC), 0.704, 0.677, 0.671, and 0.681 for TBI vs. HC, 0.739, 0.742, 0.635, and 0.766 for PTSD comorbid with TBI vs HC, and 0.726, 0.723, 0.636, and 0.747 for PTSD vs. TBI. Comorbid alcohol abuse, major depressive disorder, and BMI are not confounders in these RF models. Markers of glucose metabolism and inflammation are among the most significant CLIA features in our models. Routine CLIA blood tests have the potential for discriminating PTSD and TBI cases from healthy controls and from each other. These findings hold promise for the development of accessible and low-cost biomarker tests as screening measures for PTSD and TBI in primary care and specialty settings.

Utilization of machine learning for identifying symptom severity military-related PTSD subtypes and their biological correlates.

We sought to find clinical subtypes of posttraumatic stress disorder (PTSD) in veterans 6-10 years post-trauma exposure based on current symptom assessments and to examine whether blood biomarkers could differentiate them. Samples were males deployed to Iraq and Afghanistan studied by the PTSD Systems Biology Consortium: a discovery sample of 74 PTSD cases and 71 healthy controls (HC), and a validation sample of 26 PTSD cases and 36 HC. A machine learning method, random forests (RF), in conjunction with a clustering method, partitioning around medoids, were used to identify subtypes derived from 16 self-report and clinician assessment scales, including the clinician-administered PTSD scale for DSM-IV (CAPS). Two subtypes were identified, designated S1 and S2, differing on mean current CAPS total scores: S2 = 75.6 (sd 14.6) and S1 = 54.3 (sd 6.6). S2 had greater symptom severity scores than both S1 and HC on all scale items. The mean first principal component score derived from clinical summary scales was three times higher in S2 than in S1. Distinct RFs were grown to classify S1 and S2 vs. HCs and vs. each other on multi-omic blood markers feature classes of current medical comorbidities, neurocognitive functioning, demographics, pre-military trauma, and psychiatric history. Among these classes, in each RF intergroup comparison of S1, S2, and HC, multi-omic biomarkers yielded the highest AUC-ROCs (0.819-0.922); other classes added little to further discrimination of the subtypes. Among the top five biomarkers in each of these RFs were methylation, micro RNA, and lactate markers, suggesting their biological role in symptom severity.

Gabapentin Enacarbil Extended-Release Versus Placebo: A Likely Responder Reanalysis of a Randomized Clinical Trial.

BACKGROUND: We reanalyzed a multisite 26-week randomized double-blind placebo-controlled clinical trial of 600 mg twice-a-day Gabapentin Enacarbil Extended-Release (GE-XR), a gabapentin prodrug, designed to evaluate safety and efficacy for treating alcohol use disorder. In the original analysis (n = 338), published in 2019, GE-XR did not differ from placebo. Our aim is to advance precision medicine by identifying likely responders to GE-XR from the trial data and to determine for likely responders if GE-XR is causally superior to placebo. METHODS: The primary outcome measure in the reanalysis is the reduction from baseline of the number of heavy drinking days (ΔHDD). Baseline features including measures of alcohol use, anxiety, depression, mood states, sleep, and impulsivity were used in a random forest (RF) model to predict ΔHDD to treatment with GE-XR based on those assigned to GE-XR. The resulting RF model was used to obtain predicted outcomes for those randomized to GE-XR and counterfactually to those randomized to placebo. Likely responders to GE-XR were defined as those predicted to have a reduction of 14 days or more. Tests of causal superiority of GE-XR to placebo were obtained for likely responders and for the whole sample. RESULTS: For likely responders, GE-XR was causally superior to placebo (p < 0.0033), while for the whole sample, there was no difference. Likely responders exhibited improved outcomes for the related outcomes of percent HDD and drinks per week. Compared with unlikely responders, at baseline likely responders had higher HDDs; lower levels of anxiety, depression, and general mood disturbances; and higher levels of cognitive and motor impulsivity. CONCLUSIONS: There are substantial causal benefits of treatment with GE-XR for a subset of patients predicted to be likely responders. The likely responder statistical paradigm is a promising approach for analyzing randomized clinical trials to advance personalized treatment.

Prevalence and Diagnosis Rates of Childhood ADHD Among Racial-Ethnic Groups in a Public Mental Health System.

OBJECTIVE: This study estimated the proportions of Hispanic and non-Hispanic white and black children ages three to 17 with a diagnosis of attention-deficit hyperactivity disorder (ADHD) receiving services from the New York State public mental health system (NYS PMHS) and their annual treated ADHD prevalence rates. Findings were compared with those of recent national studies of general population samples. METHODS: Data were from a 2011 survey of users of NYS PMHS nonresidential services. Adjusted odds ratios compared the probability of an ADHD diagnosis among the groups by age, gender, and insurance type. Prevalence rates were compared among groups by age and gender. RESULTS: An estimated 133,091 children used the NYS PMHS, of whom 31% had an ADHD diagnosis. The prevalence rate of ADHD among whites was significantly lower than that among Hispanics or blacks in all gender and age groups except Hispanic females ages 13 to 17. White children were significantly less likely than black children to receive an ADHD diagnosis. CONCLUSIONS: National studies have reported higher ADHD rates among white children. Compared with children in the NYS PMHS, those in national studies had multiple access points to care, including private psychiatrists and clinicians and primary care practitioners. The higher reported ADHD rates in national studies may reflect higher rates of private insurance among white children, which would increase the likelihood of their using private practitioners. Cultural factors that influence whether and where care is sought and whether practitioners appropriately diagnosis ADHD may also explain the difference in findings.

Cultural Activation of Consumers.

This column discusses "cultural activation," defined as a consumer's recognition of the importance of providing cultural information to providers about cultural affiliations, challenges, views about, and attitudes toward behavioral health and general medical health care, as well as the consumer's confidence in his or her ability to provide this information. An aid to activation, "Cultural Activation Prompts," and a scale that measures a consumer's level of activation, the Cultural Activation Measurement Scale, are described. Suggestions are made about ways to introduce cultural activation as a component of usual care.

Access to and use of non-inpatient services in New York State among racial-ethnic groups.

OBJECTIVE Nationwide studies contrasting service use of racial-ethnic groups provide an overview of disparities, but because of variation in populations and service systems, local studies are required to identify specific targets for remedial action. The authors report on the use of non-inpatient services regulated in New York State (NYS) and report use by the state's larger cultural groups. METHODS Data from the NYS Patient Characteristics Survey were used to estimate annual treated prevalence and treatment intensity, defined as the average number of annual weeks in service for non-Hispanic blacks, Hispanics, Asians, and non-Hispanic whites. The latter rates were obtained for specific types of treatment use, by person's age and diagnosis, for the state and for population density-defined regions. Statistical methods contrasted rates of whites with other groups. RESULTS A total of 578,496 individuals in these racial-ethnic groups were served in 2,500 programs, and 51% of those served were nonwhite. Treated prevalence rates of whites were lower than those of blacks and Hispanics and were substantially higher than prevalence rates for Asians. Statewide treatment intensity rates of all racial-ethnic and age groups were comparable except for lower use among Asians >65. Key findings from granular analyses were lower treatment intensity rates for black youths with disruptive disorders, Hispanic adults with anxiety disorders, and Asians >65 with depression compared with white counterparts. In upstate metropolitan areas, black youths and Hispanic adults received services in fewer weeks than whites, and in the New York City metropolitan area, whites >65 had higher treatment intensity rates than contrast groups. CONCLUSIONS Findings suggest a need for assistance to black families in negotiating the multiple systems used by their children, clinical training focusing on cultural symptom presentation, screening of Asians in community settings, and mandated cultural competency assessments for all programs.

Declining use of electroconvulsive therapy in United States general hospitals.

BACKGROUND: Falling duration of psychiatric inpatient stays over the past 2 decades and recent recommendations to tighten federal regulation of electroconvulsive therapy (ECT) devices have focused attention on trends in ECT use, but current national data have been unavailable. METHODS: We calculated the annual number of inpatient stays involving ECT and proportion of general hospitals conducting the procedure at least once in the calendar year with a national sample of discharges from 1993 to 2009. We estimated adjusted probabilities that inpatients with severe recurrent major depression (n = 465,646) were treated in a hospital that conducts ECT and, if so, received the procedure. RESULTS: The annual number of stays involving ECT fell from 12.6 to 7.2/100,000 adult US residents, driven by dramatic declines among elderly persons, whereas the percentage of hospitals conducting ECT decreased from 14.8% to 10.6%. The percentage of stays for severe recurrent major depression in hospitals that conducted ECT fell from 70.5% to 44.7%, whereas receipt of ECT where conducted declined from 12.9% to 10.5%. For depressed inpatients, the adjusted probability that the treating hospital conducts ECT fell 34%, whereas probability of receiving ECT was unchanged for patients treated in facilities that conducted the procedure. Adjusted declines were greatest for elderly persons. Throughout the period inpatients from poorer neighborhoods or who were publicly insured or uninsured were less likely to receive care from hospitals conducting ECT. CONCLUSIONS: Electroconvulsive therapy use for severely depressed inpatients has fallen markedly, driven exclusively by a decline in the probability that their hospital conducts ECT.

Racial differences in the availability and use of electroconvulsive therapy for recurrent major depression.

BACKGROUND: Black Americans with depression were less likely to receive electroconvulsive therapy (ECT) than whites during the 1970s and 80s. This pattern was commonly attributed to treatment of blacks in lower quality hospitals where ECT was unavailable. We investigated whether a racial difference in receiving ECT persists, and, if so, whether it arises from lesser ECT availability or from lesser ECT use within hospitals conducting the procedure. METHODS: Black or white inpatient stays for recurrent major depression from 1993 to 2007 (N=419,686) were drawn from an annual sample of US community hospital discharges. The marginal disparity ratio estimated adjusted racial differences in the probabilities of (1) admission to a hospital capable of conducting ECT (availability), and (2) ECT utilization if treated where ECT is conducted (use). RESULTS: Across all hospitals, the probability of receiving ECT for depressed white inpatients (7.0%) greatly exceeded that for blacks (2.0%). Probability of ECT availability was slightly greater for whites than blacks (62.0% versus 57.8%), while probability of use was markedly greater (11.8% versus 3.9%). The white versus black marginal disparity ratio for ECT availability was 1.07 (95% confidence interval 1.06-1.07) and stable over the period, while the ratio for use fell from 3.2 (3.1-3.4) to 2.5 (2.4-2.7). LIMITATIONS: Depressed persons treated in outpatient settings or receive no care are excluded from analyses. CONCLUSIONS: Depressed black inpatients continue to be far less likely than whites to receive ECT. The difference arises almost entirely from lesser use of ECT within hospitals where it is available.

The Nathan Kline Institute cultural competency assessment scale: psychometrics and implications for disparity reduction.

The NKI Cultural Competency Assessment Scale measures organizational CC in mental health outpatient settings. We describe its development and results of tests of its psychometric properties. When tested in 27 public mental health settings, factor analysis discerned three factors explaining 65% of the variance; each factor related to a stage of implementation of CC. Construct validity and inter-rater reliability were satisfactory. In tests of predictive validity, higher scores on items related to linguistic and service accommodations predicted a reduction in service disparities for engagement and retention outcomes for Hispanics. Disparities for Blacks essentially persisted independent of CC scores.

Tenant outcomes in supported housing and community residences in New York City.

OBJECTIVE: This study examined whether outcomes in housing, clinical status, and well-being of persons with severe mental illness and a history of homelessness differ between those in supported housing and those in community residences, two housing arrangements that substantially differ in the level of independence that is offered to its tenants. METHODS: A quasi-experimental 18-month follow-up study was conducted with 157 persons newly entering supported housing and community residences. The housing models accepted persons with similar illness characteristics and homelessness histories, so that the inability to randomly assign tenants to housing types could be compensated for by propensity scoring methods. Tenure in housing was examined by using survival models. Analyses of other outcomes used hierarchical linear and regression models in both intent-to-treat (N=139) and true-stayer (N=80) analyses. RESULTS: Tenure in housing did not differ by housing type. Substantial proportions of tenants in both models remained housed during the follow-up period. Tenants in supported housing reported greater housing satisfaction in terms of autonomy and economic viability. Over time some tenants in supported housing reported greater feelings of isolation. Independent of housing type, symptoms of depression or anxiety at housing entry increased the risk of poorer outcomes. CONCLUSIONS: The models of supported housing were viable portals of entry into community housing for homeless persons, even for consumers with characteristics indicating that they would have been more likely to be placed in community residences. The results suggest that greater clinical attention should be paid to persons who exhibit depression or anxiety when entering housing.

Estimating capacity requirements for mental health services after a disaster has occurred: a call for new data.

OBJECTIVES: We sought to estimate the extended mental health service capacity requirements of persons affected by the September 11, 2001, terrorist attacks. METHODS: We developed a formula to estimate the extended mental health service capacity requirements following disaster situations and assessed availability of the information required by the formula. RESULTS: Sparse data exist on current services and supports used by people with mental health problems outside of the formal mental health specialty sector. There also are few systematically collected data on mental health sequelae of disasters. CONCLUSIONS: We recommend research-based surveys to understand service usage in non-mental health settings and suggest that federal guidelines be established to promote uniform data collection of a core set of items in studies carried out after disasters.