Identifying Which Place Characteristics are Associated with the Odds of Recent HIV Testing in a Large Sample of People Who Inject Drugs in 19 US Metropolitan Areas.

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.

Response rate profiles for major depressive disorder: Characterizing early response and longitudinal nonresponse.

BACKGROUND: Definition of response is critical when seeking to establish valid predictors of treatment success. However, response at the end of study or endpoint only provides one view of the overall clinical picture that is relevant in testing for predictors. The current study employed a classification technique designed to group subjects based on their rate of change over time, while simultaneously addressing the issue of controlling for baseline severity. METHODS: A set of latent class trajectory analyses, incorporating baseline level of symptoms, were performed on a sample of 344 depressed patients from a clinical trial evaluating the efficacy of cognitive behavior therapy and two antidepressant medications (escitalopram and duloxetine) in patients with major depressive disorder. RESULTS: Although very few demographic and illness-related features were associated with response rate profiles, the aggregated effect of candidate genetic variants previously identified in large pharmacogenetic studies and meta-analyses showed a significant association with early remission as well as nonresponse. These same genetic scores showed a less compelling relationship with endpoint response categories. In addition, consistent nonresponse throughout the study treatment period was shown to occur in different subjects than endpoint nonresponse, which was verified by follow-up augmentation treatment outcomes. CONCLUSIONS: When defining groups based on the rate of change, controlling for baseline depression severity may help to identify the clinically relevant distinctions of early response on one end and consistent nonresponse on the other.

HIV Infection Among People Who Inject Drugs in the United States: Geographically Explained Variance Across Racial and Ethnic Groups.

OBJECTIVES: We explored how variance in HIV infection is distributed across multiple geographical scales among people who inject drugs (PWID) in the United States, overall and within racial/ethnic groups. METHODS: People who inject drugs (n = 9077) were recruited via respondent-driven sampling from 19 metropolitan statistical areas (MSAs) for the Centers for Disease Control and Prevention's 2009 National HIV Behavioral Surveillance system. We used multilevel modeling to determine the percentage of variance in HIV infection explained by zip codes, counties, and MSAs where PWID lived, overall and for specific racial/ethnic groups. RESULTS: Collectively, zip codes, counties, and MSAs explained 29% of variance in HIV infection. Within specific racial/ethnic groups, all 3 scales explained variance in HIV infection among non-Hispanic/Latino White PWID (4.3%, 0.2%, and 7.5%, respectively), MSAs explained variance among Hispanic/Latino PWID (10.1%), and counties explained variance among non-Hispanic/Latino Black PWID (6.9%). CONCLUSIONS: Exposure to potential determinants of HIV infection at zip codes, counties, and MSAs may vary for different racial/ethnic groups of PWID, and may reveal opportunities to identify and ameliorate intraracial inequities in exposure to determinants of HIV infection at these geographical scales.

Changes in Exposure to Neighborhood Characteristics are Associated with Sexual Network Characteristics in a Cohort of Adults Relocating from Public Housing.

Ecologic and cross-sectional multilevel analyses suggest that characteristics of the places where people live influence their vulnerability to HIV and other sexually-transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African-American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater post-relocation improvements in economic disadvantage, violent crime, and male:female sex ratios would experience greater reductions in perceived partner risk and in the odds of having a partner who had another partner (i.e., indirect concurrency). Baseline data were collected from 172 public housing residents before relocations occurred; three waves of post-relocation data were collected every 9 months. Participants who experienced greater improvements in community violence and in economic conditions experienced greater reductions in partner risk. Reduced community violence was associated with reduced indirect concurrency. Structural interventions that decrease exposure to violence and economic disadvantage may reduce vulnerability to HIV/STIs.

Preliminary Findings Supporting Insula Metabolic Activity as a Predictor of Outcome to Psychotherapy and Medication Treatments for Depression.

A putative right anterior insula metabolism biomarker predictive of treatment outcomes was retrospectively applied to 30 depressed psychotherapy--or escitalopram-treated nonremitters who entered combination treatment. Patients whose added treatment matched the biomarker-indicated treatment remitted more often than biomarker-mismatched patients.

Impact of public housing relocations: are changes in neighborhood conditions related to STIs among relocaters?

BACKGROUND: Cross-sectional and ecologic studies suggest that place characteristics influence sexual behaviors and sexually transmitted infections (STIs). Using data from a predominately substance-misusing cohort of African American adults relocating from US public housing complexes, this multilevel longitudinal study tested the hypothesis that participants who experienced greater postrelocation improvements in neighborhood conditions (i.e., socioeconomic disadvantage, social disorder, STI prevalence, and male/female sex ratios) would have reduced the odds of testing positive for an STI over time. METHODS: Baseline data were collected in 2009 from 172 public housing residents before relocations occurred; 3 waves of postrelocation data were collected every 9 months thereafter. Polymerase chain reaction methods were used to test participants' urine for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Individual-level characteristics were assessed via survey. Administrative data described the census tracts where participants lived at each wave (e.g., sex ratios, violent crime rates, and poverty rates). Hypotheses were tested using multilevel models. RESULTS: Participants experienced improvements in all tract-level conditions studied and reductions in STIs over time (baseline: 29% tested STI positive; wave 4: 16% tested positive). Analyses identified a borderline statistically significant relationship between moving to tracts with more equitable sex ratios and reduced odds of testing positive for an STI (odds ratio, 0.16; 95% confidence interval, 0.02-1.01). Changes in other neighborhood conditions were not associated with this outcome. DISCUSSION: Consonant with past research, our findings suggest that moving to areas with more equitable sex ratios reduces the risk of STI infection. Future research should study the extent to which this relationship is mediated by changes in sexual network dynamics.

Neuropsychological function before and after subcallosal cingulate deep brain stimulation in patients with treatment-resistant depression.

BACKGROUND: Treatment-resistant depression (TRD) is a pervasive and difficult to treat condition for which deep brain stimulation (DBS) of the subcallosal cingulate white matter (SCCwm) is an emerging therapeutic option. However, neuropsychological safety data for this novel treatment have only been published for a small number of subjects. Moreover, little is known regarding the neuropsychological profile present in TRD patients at baseline, prior to initiation of DBS therapy. This report describes the neuropsychological effects of TRD and acute and chronic DBS of the SCCwm in patients with unipolar and bipolar TRD. METHODS: Patients with TRD (N = 17) were compared to a healthy control group (N = 15) on subtests from the Cambridge Neuropsychological Test Automated Battery and the Stroop Task. Patients were then tested again at subsequent time points of 1 and 6 months following the initiation of chronic DBS of the SCCwm. RESULTS: Patients with TRD showed similar levels of performance to healthy controls on most neuropsychological measures, with the exception that the TRD group had slower processing speed. Patients with bipolar TRD, relative to those with unipolar TRD, obtained lower scores on measures of executive function and memory only at baseline. With acute and chronic SCCwm DBS, neuropsychological function improved in multiple domains including processing speed and executive function (planning, set shifting, response inhibition), and memory remained stable. CONCLUSIONS: Patients with TRD show slowed processing speed but otherwise largely preserved neuropsychological functioning. DBS of the SCCwm does not result in worsening of any aspect of neuropsychological function and may improve certain domains. Future research is warranted to better understand the effects of TRD and DBS on neuropsychological function.

Enhancing Hispanic participation in mental health clinical research: development of a Spanish-speaking depression research site.

BACKGROUND: Hispanics, particularly those with limited English proficiency, are underrepresented in psychiatric clinical research studies. We developed a bilingual and bicultural research clinic dedicated to the recruitment and treatment of Spanish-speaking subjects in the Predictors of Remission in Depression to Individual and Combined Treatments (PReDICT) study, a large clinical trial of treatment-naïve subjects with major depressive disorder (MDD). METHODS: Demographic and clinical data derived from screening evaluations of the first 1,174 subjects presenting for participation were compared between the Spanish-speaking site (N = 275) and the primary English-speaking site (N = 899). Reasons for ineligibility (N = 888) for the PReDICT study were tallied for each site. RESULTS: Compared to English speakers, Spanish speakers had a lower level of education and were more likely to be female, uninsured, and have uncontrolled medical conditions. Clinically, Spanish speakers demonstrated greater depression severity, with higher mean symptom severity scores, and a greater number of previous suicide attempts. Among the subjects who were not randomized into the PReDICT study, Spanish-speaking subjects were more likely to have an uncontrolled medical condition or refuse participation, whereas English-speaking subjects were more likely to have bipolar disorder or a non-MDD depressive disorder. CONCLUSION: Recruitment of Hispanic subjects with MDD is feasible and may enhance efforts at signal detection, given the higher severity of depression among Spanish-speaking participants presenting for clinical trials. Specific approaches for the recruitment and retention of Spanish-speaking participants are required.

The aftermath of public housing relocations: relationships between changes in local socioeconomic conditions and depressive symptoms in a cohort of adult relocaters.

USA is experiencing a paradigm shift in public housing policy: while policies used to place people who qualified for housing assistance into spatially concentrated housing complexes, they now seek to geographically disperse them, often to voucher-subsidized rental units in the private market. Programs that relocate residents from public housing complexes tend to move them to neighborhoods that are less impoverished and less violent. To date, studies have reached conflicting findings about the relationship between public housing relocations and depression among adult relocaters. The present longitudinal multilevel analysis tests the hypothesis that pre-/postrelocation improvements in local economic conditions, social disorder, and perceived community violence are associated with declines in depressive symptoms in a cohort of African-American adults; active substance misusers were oversampled. We tested this hypothesis in a cohort of 172 adults who were living in one of seven public housing complexes scheduled for relocation and demolition in Atlanta, GA; by design, 20% were dependent on substances and 50% misused substances but were not dependent. Baseline data captured prerelocation characteristics of participants; of the seven census tracts where they lived, three waves of postrelocation data were gathered approximately every 9 months thereafter. Surveys were administered at each wave to assess depressive symptoms measured using the Center for Epidemiologic Studies Depression Scale (CES-D), perceived community violence, and other individual-level covariates. Participants' home addresses were geocoded to census tracts at each wave, and administrative data sources were used to characterize tract-level economic disadvantage and social disorder. Hypotheses were tested using multilevel models. Between waves 1 and 2, participants experienced significant improvements in reported depressive symptoms and perceived community violence and in tract-level economic disadvantage and social disorder; these reductions were sustained across waves 2-4. A 1 standard deviation improvement in economic conditions was associated with a 1-unit reduction in CES-D scores; the magnitude of this relationship did not vary by baseline substance misuse or gender. Reduced perceived community violence also predicted lower CES-D scores. Our objective measure of social disorder was unrelated to depressive symptoms. We found that relocaters who experienced greater pre-/postrelocation improvements in economic conditions or in perceived community violence experienced fewer depressive symptoms. Combined with past research, these findings suggest that relocation initiatives should focus on the quality of the places to which relocaters move; future research should also identify pathways linking pre-/postrelocation changes in place characteristics to changes in mental health.

Design of a randomized clinical trial of brief couple therapy for PTSD augmented with intranasal oxytocin.

BACKGROUND: Leveraging military veterans' intimate relationships during treatment has the potential to concurrently improve posttraumatic stress disorder (PTSD) symptoms and relationship quality. Cognitive-Behavioral Conjoint Therapy (CBCT) and an 8-session Brief Cognitive-Behavioral Conjoint Therapy (bCBCT) are manualized treatments designed to simultaneously improve PTSD and relationship functioning for couples in which one partner has PTSD. Although efficacious in improving PTSD, the effects of CBCT on relationship satisfaction are small, especially among veterans. Intranasal oxytocin, which targets mechanisms of PTSD and relationship quality, may enhance the efficacy of bCBCT. METHOD/DESIGN: The purpose of this 4-year clinical trial is to compare the outcomes of bCBCT augmented with intranasal oxytocin versus bCBCT plus placebo. We will also explore potential mechanisms of action: self-reported communication skills, empathy, and trust. We will recruit 120 dyads (i.e., veteran with PTSD and their intimate partner) from the VA San Diego Healthcare System. Veterans will be administered 40 international units of oxytocin (n = 60) or placebo (n = 60) 30 min before each of 8 bCBCT sessions delivered via telehealth. Clinical and functioning outcomes will be assessed at five timepoints (baseline, mid-treatment, post-treatment, and 3- and 6-month follow-up). CONCLUSION: Study findings will reveal the efficacy of oxytocin-assisted brief couple therapy for PTSD, which could serve as highly scalable option for couples coping with PTSD, as well as provide preliminary evidence of interpersonal mechanisms of change. CLINICALTRIALS: govIdentifier:NCT06194851.

Effect of meditation on endothelial function in Black Americans with metabolic syndrome: a randomized trial.

OBJECTIVES: Psychological stress may play a role in metabolic syndrome. A consequence of metabolic syndrome is endothelial dysfunction, which is also influenced by psychological stress. We sought to compare the effect of consciously resting meditation (CRM), a sound based meditation, with a control intervention of health education (HE) on endothelial function in the setting of metabolic syndrome. METHODS: Sixty-eight black Americans with metabolic syndrome risk factors (age, 30-65 years) were randomized to either CRM (n = 33) or HE (n = 35); interventions were matched for frequency and duration of sessions and lasted 12 months. Endothelial function was assessed by brachial artery flow-mediated dilation at baseline and at 6 and 12 months. Arterial elasticity, metabolic risk factors, and psychosocial and behavioral variables were secondary end points. RESULTS: Although flow-mediated dilation improved in the CRM group for 12 months, this increase was not significantly higher than that in the HE group (p = .51 for the interaction between group and time). Non-endothelium-dependent dilation and arterial elasticity did not change in either group. Most metabolic syndrome risk factors showed beneficial trends in the CRM group only. A risk factor score counting the number of metabolic syndrome components decreased in the CRM group only (p = .049 for the interaction between treatment group and time). CONCLUSIONS: Among black Americans with metabolic syndrome risk factors, CRM, did not improve endothelial function significantly more than a control intervention of HE. CRM resulted in favorable trends in metabolic syndrome risk factors, which were examined as secondary outcomes.

Opening Doors to Recovery: A Randomized Controlled Trial of a Recovery-Oriented Community Navigation Service for Individuals With Serious Mental Illnesses and Repeated Hospitalizations.

Objective: Opening Doors to Recovery (ODR) is a community navigation and recovery support model created in southeast Georgia by diverse, collaborative stakeholders. Following promising results from a quasi-experimental study, this randomized controlled trial hypothesized that, among patients with serious mental illnesses being discharged from inpatient psychiatric settings, compared to those randomized to traditional case management (CM) services, those randomized to ODR would have (1) lower likelihood of hospitalization, fewer hospitalizations, and fewer inpatient days; (2) lower likelihood of arrest, fewer arrests, and longer time to arrest; and, secondarily, (3) greater housing satisfaction and housing stability; and (4) higher scores on several scales measuring recovery-related constructs.Methods: 240 individuals with Structured Clinical Interview for DSM-5 Disorders-based psychotic or mood disorders, functional impairment, and repeated hospitalizations were randomized (December 2014 to June 2018) to ODR or CM. Hospitalization and arrest data were collected from State agencies after 12 months, and housing- and recovery-related measures were collected in person, longitudinally at 4, 8, and 12 months. Intention-to-treat analyses were conducted. Effects of dropout were accounted for, and sensitivity analyses were run.Results: ODR was associated with fewer days hospitalized (RR = 0.86, P = .001), a lower incidence of arrests (OR = 0.35, P < .0005), and longer time to arrest (HR = 0.42, P = .001). In addition, measures of housing satisfaction (Cohen d = 0.45) and recovery (Cohen d = 0.33) were significantly more improved in ODR patients compared to CM patients.Conclusions: The ODR model appears to have advantages over more traditional CM services and could fill a gap in the service array. Studying the mediators of success, cost benefit, dissemination, fidelity, and financing of the model is warranted.Trial Registration: ClinicalTrials.gov identifier: NCT04612777.

The Illness Density Index (IDI): A longitudinal measure of treatment efficacy.

BACKGROUND: A reliable and meaningful quantitative index of success is paramount in the trial of any new treatment. However, existing methods for defining response and remission for treatments tested for psychiatric disorders are limited in that they often minimize the variance in change over time among individual patients and generally use arbitrarily chosen levels of functioning at specified times during treatment. PURPOSE: To suggest and determine the properties of an alternative measure of treatment success, the Illness Density Index (IDI), that may be more sensitive to fluctuations in symptoms over the course of treatment compared to existing measures. METHODS: We examined data from 64 depressed patients with multiple assessments of the Hamilton Depression Rating Scale (HDRS) over 12 weeks of randomized treatment in order to compare and contrast varying numerical definitions of response and remission, including percent change and linear slope over time. RESULTS: Examination of the indices comparing the within-sample rank of individual patients revealed that these indices agree in cases where patients have little or no response as well as clear and sustained response, while they differ in patients who have a slow (or late) response as well as relapse during the treatment course. LIMITATIONS: The measure may not be useful for all types of studies, especially short-term treatment trials. CONCLUSIONS: The IDI is highly correlated with both categorical (e.g., remission) and continuous (e.g., percent change) definitions of treatment success. Furthermore, it differentiates certain trajectories of change that current definitions do not. Thus, the proposed index may be a valuable addition to current measures of efficacy, especially when trying to identify biological substrates of illness or predictors of long-term outcome.

Predictors of the discharge dosage of an atypical antipsychotic agent among hospitalized, treatment-naive, first-episode psychosis patients in naturalistic, public-sector settings.

OBJECTIVE: Little is known about determinants of second-generation antipsychotic dosages during initial hospitalization of first-episode psychosis. This study examined potential predictors of dosage of an atypical antipsychotic agent, risperidone, at hospital discharge after initial evaluation and treatment of first-episode nonaffective psychosis in 3 naturalistic, public-sector treatment settings. METHODS: The number of psychotropic agents prescribed and discharge antipsychotic dosage were abstracted from the medical record. Demographic and extensive clinical characteristics were assessed through a clinical research study conducted at the 3 sites. One-way analyses of variance, trend tests using specific linear combinations of estimates, and χ² tests assessed for associations between atypical antipsychotic dosage and 5 hypothesized predictors, as well as 12 exploratory variables. RESULTS: Among 155 hospitalized first-episode patients, 121 (78.1%) were discharged on risperidone, and subsequent analyses focused on that subset. The mean risperidone dosage among those 121 patients was 4.26 mg; 31 received 1 to 2 mg, 45 received 3 to 4 mg, 37 received 5 to 6 mg, and 8 received more than 6 mg. Analyses suggested that older age at hospitalization, the number of psychotropic agents prescribed, excited symptoms, and premorbid social functioning may be predictors of the discharge dosage. CONCLUSIONS: Although several factors emerged, in general, predictors of discharge dosages of second-generation agents, here exemplified by risperidone, in real-world practice settings remain to be clarified. Given the importance of antipsychotic initiation during first hospitalization, future research should test an even broader array of potential predictors.

Group motivational interviewing to promote adherence to antiretroviral medications and risk reduction behaviors in HIV infected women.

We present the results of a clinical trial that tested the efficacy of using motivational interviewing (MI) in a group format to promote adherence to antiretroviral medications and risk reduction behaviors (RRB) in 203 predominately African American HIV infected women. It was compared to a group health promotion program. Participants were followed for 9 months. Adherence was measured by MEMS(®); and RRB by self-report. Controlling for recruitment site and years on ART, no significant group by time effects were observed. Attendance (≥7/8 sessions) modified the effects. Higher MI attendees had better adherence at all follow-ups, a borderline significant group by time effect (p = 0.1) for % Doses Taken on Schedule, a significantly larger proportion who reported abstinence at 2 weeks, 6, and 9 months, and always used protection during sex at 6 and 9 months. Though not conclusive, the findings offer some support for using MI in a group format to promote adherence and some risk reduction behaviors when adequate attendance is maintained.

Adversity in childhood/adolescence and premorbid tobacco, alcohol, and cannabis use among first-episode psychosis patients.

AIM: Premorbid substance use is widely recognized as a crucial factor in early psychosis. We explored the effects of childhood/adolescent adversity on premorbid tobacco, alcohol, and cannabis use. We hypothesized that adversity in childhood would be associated with an increased likelihood of use, and amount of intake, of tobacco, alcohol, and cannabis. We analysed which domains of adversity have the greatest impact. METHODS: First-episode psychosis patients were enrolled from six inpatient psychiatric units in Atlanta, Georgia and Washington, D.C. Premorbid substance use was thoroughly measured, and childhood/adolescent adversity was rated using 14 scales/subscales. Factor analysis was used to reduce these scales/subscales to the three domains of adversity (termed Violence and Environmental Adversity, Interpersonal Abuse, and Neglect and Lack of Connectedness). Regression analyses determined associations between adversity domains and premorbid substance use. RESULTS: Our sample (n = 247) primarily consisted of African Americans (86.2%) and males (74.5%). Violence and Environmental Adversity was significantly associated with five of six substance use variables and marginally associated with the sixth. Interpersonal Abuse was unassociated with substance use, and Neglect and Lack of Connectedness was associated only with a lower likelihood cannabis use. When Violence and Environmental Adversity results were stratified by gender, effects on tobacco use and amount of tobacco use were stronger among females. CONCLUSIONS: Childhood/adolescent trauma and adversity have meaningful associations with premorbid substance use in first-episode psychosis patients. First-episode psychosis and clinical high-risk treatment settings may benefit from expanding the assessment of childhood/adolescent adversity to include factors pertaining to violence exposure and adversities beyond abuse and neglect.

Symptomatology and neurocognition among first-episode psychosis patients with and without cannabis use in the three months prior to first hospitalization.

OBJECTIVE: The nature of associations between recent cannabis use and negative symptoms, positive symptoms, and neurocognitive deficits remains unclear. In a relatively large sample of well-characterized patients with first-episode psychosis, we hypothesized that, compared to first-episode patients without cannabis use in the three months prior to first hospitalization, those having used cannabis would have lesser negative symptoms, greater positive symptoms, and no differences in cognitive functioning. Dose-response relationships were also examined. METHODS: Between 2008 and 2013, 247 first-episode psychosis patients were assessed during their hospitalization at one of six participating inpatient psychiatric units. Measures included the Longitudinal Substance Use Recall for 12 Weeks instrument, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, and the MATRICS Consensus Cognitive Battery (MCCB). RESULTS: Anhedonia-asociality was significantly lower among those using cannabis in the past three months (10.7±4.6 v. 12.1±4.4, p=.023). Delusions were more severe among those having used cannabis (19.3±8.4 v. 15.9±9.1, p=.005), as was bizarre behavior (p=.01). There were no significant differences between those using and not using cannabis across nine MCCB measures. Correlations between the "dose" of cannabis and all of these measures were not significant. CONCLUSIONS: Compared to those without cannabis use, those who use cannabis in recent months have lesser anhedonia-asociality, greater delusion and bizarre behavior severity, and no significant differences in neurocognition. Such characterizations could shed light on subgroups of individuals with first-episode psychosis, as well as risk factors for cannabis use in the early course of these disorders.

Associations Between Childhood and Adolescence Adversity and Risk for Arrest Among Patients With First-Episode Psychosis.

OBJECTIVE: The authors assessed associations between childhood and adolescent adversity and arrest among individuals with first-episode psychosis (FEP). The authors also sought to determine which domains of adversity had the greatest impact and whether associations varied by gender. METHODS: Data were analyzed from 247 patients with FEP admitted to inpatient psychiatric units between August 2008 and June 2013. Analyses focused on self-reported history of arrest and seven scales of past adversity, with 14 subscales reduced to three factors. Binary logistic regression and negative binomial regression determined associations between the three childhood adversity factors and having ever been arrested and number of arrests, respectively. RESULTS: Past experience of violence and environmental adversity was significantly (p<0.001) associated with both history of arrest (odds ratio=2.29) and number of arrests (ß=0.60), and this association was stronger for female patients than for male patients. CONCLUSIONS: Findings suggest a need to address both past adversity and criminal justice system involvement in the context of early psychosis specialty care.

Development and validation of the HIV adolescent readiness for transition scale (HARTS) in South Africa.

INTRODUCTION: Adolescents living with perinatally acquired HIV have low rates of retention in care and viral suppression after the transition from paediatric to adult care. In this study, we developed and validated a tool to identify adolescent transition readiness. METHODS: We developed the HIV Adolescent Readiness for Transition Scale (HARTS) from June 2016 to May 2019 by iteratively adapting existing transition readiness scales for other chronic illnesses by conducting focus groups with 11 healthcare providers and 20 adolescents in South Africa. We administered a preliminary questionnaire to 131 adolescents to determine psychometric properties and assess test-retest variability. We used confirmatory factor analysis to verify the proposed scale structure using the underlying variable approach. We correlated responses to self-described transition readiness and age using linear regression. We subsequently validated the scale by prospectively administering it to 199 adolescents in a second South African setting before their transition. We then used multivariable logistic regression to assess the effects of the HARTS and relevant socio-behavioural covariates on viral suppression one year after transition. RESULTS: We identified four domains relevant to transition readiness: disclosure, health navigation, self-advocacy and health literacy. Fifteen questions with a significant factor loading of 0.3 to 0.9 were identified. No significant test-retest variability was seen among 10% of participants. Positive correlations with self-described transition readiness were significant with the overall HARTS and domains of health navigation, self-advocacy and health literacy. In the prospective analysis, for adolescents not using drugs, each 10-point increase in the HARTS was associated with 0.62 odds of viral failure (95% CI 0.45 to 0.86; p = 0.004). The individual domains of self-advocacy (AOR 0.56; 95% CI 0.33 to 0.94; p = 0.029), disclosure (AOR 0.02; 95% CI 0.01 to 0.25; p = 0.002), health navigation (AOR 0.51; 95%CI 0.25 to 1.02; p = 0.056) and health literacy (AOR 0.37; 95% CI 0.10 to 1.30; p = 0.121) were associated with viral failure adjusting for age at antiretroviral therapy initiation, ART regimen, sex, disclosure status, and alcohol use in both analyses. CONCLUSIONS: The HARTS is a validated scale that can be used to identify which adolescents may require additional interventions prior to transitioning to adult care to improve viral suppression after transition.

Establishing Evidence for Clinical Utility of a Neuroimaging Biomarker in Major Depressive Disorder: Prospective Testing and Implementation Challenges.

BACKGROUND: Although a number of neuroimaging biomarkers for response have been proposed, none have been tested prospectively for direct effects on treatment outcomes. To the best of our knowledge, this is the first prospective test of the clinical utility of the use of an imaging biomarker to select treatment for patients with major depressive disorder. METHODS: Eligible participants (n = 60) had a primary diagnosis of major depressive disorder and were assigned to either escitalopram or cognitive behavioral therapy based on fluorodeoxyglucose positron emission tomography activity in the right anterior insula. The overall study remission rate after 12 weeks of treatment, based on the end point Hamilton Depression Rating Scale score, was then examined for futility and benefit of the strategy. RESULTS: Remission rates demonstrated lack of futility at the end of stage 1 (37%, 10/27), and the study proceeded to stage 2. After adjustment for the change in stage 2 sample size, the complete remission rate did not demonstrate evidence of benefit (37.7%, 95% confidence interval, 26.3%-51.4%, p = .38). However, total remission rates (complete and partial remission) did reach significance in post hoc analysis (49.1%, 95% confidence interval, 37.6%-60.7%, p = .020). CONCLUSIONS: The study shows some evidence for a role of the right anterior insula in the clinical choice of major depressive disorder monotherapy. The effect size, however, is insufficient for the use of insula activity as a sole predictive biomarker of remission. The study also demonstrates the logistical difficulties in establishing clinical utility of biomarkers.