Effect of coinfections on neurocognitive functioning among people with clade C HIV infection in Zambia.

Despite the fact that many coinfections in people with HIV (PWH) are treatable or suppressible, they may still impact neurocognitive (NC) functioning. Here, we aim to evaluate the presence of latent/treated coinfections and their association with NC functioning in a cohort of PWH in Zambia. We carried out a cross-sectional, nested study involving 151 PWH with viral suppression, and a normative sample of 324 adults without HIV. Plasma samples from PWH who underwent a comprehensive NC assessment were evaluated for the presence of treated/latent coinfections that are common in Zambia. Information about treated pulmonary tuberculosis (TB) was obtained from participants' clinical charts. Overall, PWH differed significantly from the HIV seronegatives on all neuropsychological domains except for fine motor control. ANOVA comparisons of all 3 HIV + groups' demographically corrected mean NC T-scores showed that the HIV + /TB + group had the poorest NC functioning in the following domains: executive functioning (F = 4.23, p = 0.02), working memory (F = 5.05, p = 0.002), verbal fluency (F = 4.24, p = 0.006), learning (F = 11.26, p < 0.001), delayed recall (F = 4.56, p = 0.01), and speed of information processing (F = 5.16, p = 0.005); this group also was substantially worse on the total battery (global mean T-scores; F = 8.02, p < 0.001). In conclusion, treated TB coinfection in PWH was associated with worse NC performance compared to both those with antibodies against other coinfections and without. PWH with antibodies for other coinfections (HIV + /CI +) showed somewhat better NC performance compared to those without (HIV + /CI -), which was not expected, although comparisons with the HIV + /CI + group are limited by its lack of specificity regarding type of coinfection being represented.

Use of Western Neuropsychological Test Battery in Detecting HIV-Associated Neurocognitive Disorders (HAND) in Zambia.

This is a study of neuroAIDS in sub-Saharan Africa, involving 266 Zambian adults infected with the human immunodeficiency virus (HIV), clade C. All HIV+ participants were receiving combination antiretroviral therapy (CART), and were administered a comprehensive neuropsychological (NP) test battery covering seven ability domains that are frequently affected by neuroAIDS. The battery was developed in the U.S. but has been validated in other international settings and has demographically-corrected normative standards based upon 324 healthy Zambian adults. Compared to the healthy Zambian controls, the HIV+ sample performed worse on the NP battery with a medium effect size (Cohen's d = 0.64). 34.6 % of the HIV+ individuals had global NP impairment and met criteria for HIV associated neurocognitive disorder (HAND). The results indicate that the Western-developed NP test battery is appropriate for use in Zambia and can serve as a viable HIV and AIDS management tool.

Isovaleric acid in stool correlates with human depression.

OBJECTIVE: Human depression is a major burden, both on the individuals who suffer from the disease and on society at large. Traditionally, depression has been linked to psychological and biological causes, but there has been increasing interest in the gut-brain axis. In this regard, we have recently shown that specific bacteria are correlated with human depression, and we hypothesize that volatile fatty acids (VFAs) are mediators. METHODS: Here, we analyzed the direct correlation between VFAs, depression and cortisol in a cohort consisting of 34 depressed patients and 17 controls. RESULTS: We found statistically significant correlations between depression and the VFA isovaleric acid, as well as between isovaleric acid and cortisol. Furthermore, bacteria that previously have been identified as being correlated with depression were also correlated with isovaleric acid. Isovaleric acid showed a bimodal distribution in which the depressed patients were overrepresented in the high level group (P < 0.00005, binominal test). DISCUSSION: It has recently been shown that gut-derived VFAs can cross the blood-brain barrier, where isovaleric acid interferes with synaptic neurotransmitter release. The multiple correlation patterns, in addition to a potential mechanistic model, point towards a potential causal relationship between depression and isovaleric acid.

Individualized goals expressed by patients undergoing stroke rehabilitation: an observational study.

OBJECTIVES: To explore the rehabilitation goals measured with the Patient-Specific Functional Scale (PSFS) in patients undergoing acute and subacute stroke rehabilitation. In addition, to assess whether PSFS goals corresponded to impairments and activity limitations, as identified by standardized measures. DESIGN: Observational study. PARTICIPANTS: A total of 71 participants undergoing inpatient stroke rehabilitation. METHODS: The PSFS goals were linked to second-level categories in the International Classification of Functioning, Disability and Health (ICF), using established linking rules. Frequencies of the linked ICF categories were calculated. Frequencies of participants with limitations in walking, activities of daily living (ADL), vision, language, and cognition, were calculated, along with goals in corresponding areas of functioning. RESULTS: The participants' goals were linked to 50 second-level ICF categories, comprising areas such as walking and moving, ADL, language, vision, and cognition. The most frequent ICF categories were "Moving around in different locations" (n = 24), "Walking" (n = 23), "Toileting" (n = 16), "Hand and arm use (n = 12) and "Fine hand use (n = 12)". Of participants with limitations in walking, cognition, and vision, 85%, 10%, and 16%, respectively, had goals in these areas. CONCLUSION: Participants' goals included walking, ADL, language, vision, and cognition. Few with impairments in cognition or vision had goals in these corresponding areas on the PSFS.

Therapeutic alliance in early schizophrenia spectrum disorders: a cross-sectional study.

BACKGROUND: The therapeutic alliance is related to better course and outcome of treatment in schizophrenia. This study explores predictors and characteristics of the therapeutic alliance in recent-onset schizophrenia spectrum disorders including the agreement between patient and therapist alliance ratings. METHODS: Forty-two patients were assessed with demographic, neurocognitive, and clinical measures including the Positive and Negative Syndrome Scale (PANSS). The therapeutic alliance was measured with the Working Alliance Inventory - Short Form (WAI-S). RESULTS: Patient WAI-S total scores were predicted by age and PANSS excitative symptoms. Therapist WAI-S total scores were predicted by PANSS insight. Patient and therapist WAI-S total scores were moderately associated. Neurocognition was not associated with working alliance. CONCLUSION: Working alliance is associated with specific demographic and symptom characteristics in patients with recent-onset schizophrenia spectrum disorders. There is moderate agreement between patients and therapists on the total quality of their working alliance. Findings highlight aspects that may increase therapists' specificity in the use of alliance-enhancing strategies.

Measurement Properties of the Patient-Specific Functional Scale in Rehabilitation for Patients With Stroke: A Prospective Observational Study.

OBJECTIVE: This study investigated the validity, reliability, responsiveness, and interpretability of the Patient-Specific Functional Scale (PSFS) in subacute stroke rehabilitation to determine its suitability to measure patient-identified rehabilitation goals. METHODS: A prospective observational study was designed according to the checklist from Consensus-Based Standards for Selecting Health Measurement Instruments. Seventy-one patients diagnosed with stroke were recruited in the subacute phase from a rehabilitation unit in Norway. The International Classification of Functioning, Disability and Health was used to assess the content validity. Assessment of construct validity was based on hypotheses for correlation of the PSFS and comparator measurements. We assessed reliability by calculating the Intraclass Correlation Coefficient (ICC) (3.1) and the standard error of measurement. The assessment of responsiveness was based on hypotheses for the correlation of change scores between the PSFS and the comparator measurements. A receiver operating characteristic analysis was conducted to assess responsiveness. The smallest detectable change and minimal important change were calculated. RESULTS: Eighty percent of the PSFS items were classified as activities and participation in the International Classification of Functioning, Disability and Health, indicating satisfactory content validity. The reliability was satisfactory with an ICC of 0.81 (95% CI = 0.69-0.89). The standard error of measurement was 0.70 point, and the smallest detectable change was 1.94 points. Five of 7 hypotheses were confirmed for construct validity, and 5 of 6 were confirmed for responsiveness, indicating moderate construct validity and high responsiveness. Assessing responsiveness with a criterion approach resulted in an area under the curve of 0.74. A ceiling effect was identified for 25% of the participants 3 months after discharge. The minimal important change was estimated to be 1.58 points. CONCLUSION: This study demonstrates satisfactory measurement properties for the PSFS in individuals undergoing inpatient stroke rehabilitation. IMPACT: This study supports the use of the PSFS to document and monitor patient-identified rehabilitation goals in patients receiving subacute stroke rehabilitation when applied using a shared decision approach.

Sex differences in neuropsychological performance as an effect of human immunodeficiency virus infection: a pilot study in Zambia, Africa.

This study examined whether there are neuropsychological performance differences between human immunodeficiency virus-seropositive participants being followed at a University of Zambia clinic and demographically comparable seronegative controls being tested for infection in the same setting. All participants were administered a standardized neurocognitive test battery that has been found sensitive to HIV-associated Neurocognitive Disorder in the United States and internationally (e.g., in China, India, Romania, and Cameroon). The test battery was found to be applicable to a Zambian population. A clear HIV effect was seen with a medium to large overall effect size (Cohen d = 0.74). However, it was only the female seropositive participants who showed this HIV effect. HIV can result in neuropsychological deficits in Zambia, where clade C of the virus dominates. It is suggested that the HIV-infected women are more at risk of developing cognitive deficits than are men in this population, possibly because of sex-related social, financial, and healthcare disadvantages. However, further analyses are required regarding this conclusion because the finding was a result of an unplanned subanalysis.

The Applicability of the Patient-Specific Functional Scale (PSFS) in Rehabilitation for Patients with Acquired Brain Injury (ABI) - A Cohort Study.

AIM: The primary aim of this study was to investigate the applicability of the Patient-Specific Functional Scale (PSFS) in patients with acquired brain injury (ABI) admitted to a specialized rehabilitation unit in a regional hospital. A secondary aim was to identify patient characteristics and functioning that predicted changes in the PSFS. PATIENTS AND METHODS: In a cohort study, 59 patients with ABI were assessed for the ability to complete the PSFS. A trained multidisciplinary team applied the PSFS as part of a collaborative development of rehabilitation goals. The modified Rankin Scale (mRS), the Functional Ambulation Categories (FAC), the Rivermead Behavioural Memory Test (RBMT), the Norwegian Basic Aphasia Assessment (NBAA) and the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) were used to identify characteristics of the sample. Multivariate regression analyses were performed to investigate associations between changes in the PSFS score from admission to discharge and a selected set of participant baseline characteristics and functioning. RESULTS: Fifty-four patients (92%) of the patients with ABI were able to complete the PSFS. The five (8%) who were unable to complete the PSFS had severe cognitive or language impairment. The PSFS score improved by a mean of 2.6 (SD 2.0) points from admission to discharge. The LOTCA score made the strongest unique contribution to explain the change in the PSFS score (beta = 0.477, p= 0.020). CONCLUSION: In the present study, most patients with ABI (92%) were able to complete the PSFS. Cognitive function on admission was a predictor of improved functioning on the PSFS.

Cognitive Impairment in Zambians With HIV Infection and Pulmonary Tuberculosis.

BACKGROUND: HIV infection may result in neurocognitive deficits, but the effects of pulmonary tuberculosis (TB+), a common comorbid condition in HIV infection, on cognition in HIV infections are unknown. Accordingly, we examined the effects of TB+, on neurocognitive functioning in HIV-infected (HIV+) Zambian adults. SETTING: All participants were drawn from HIV clinics in and around Lusaka, the capital of Zambia. METHODS: Participants were 275 HIV+, of whom 237 were HIV+ and TB-negative (HIV+/TB-), and 38 also had pulmonary TB+ (HIV+/TB+). Controls were 324 HIV- and TB-uninfected (HIV-) healthy controls. All HIV+ participants were prescribed combination antiretroviral treatment (cART). Published, demographically corrected Zambian neuropsychological norms were used to correct for effects of age, education, sex, and urban/rural residence. RESULTS: Neuropsychological deficits, assessed by global deficit scores, were more prevalent in this order: 14% (46 of 324) of HIV- controls, 34% (80 of 237) of HIV+/TB-, and 55% (21 of 38) of HIV+/TB+ group. Thus, both HIV-infected groups evidenced more impairment than HIV- controls, and the HIV+/TB+ group had a higher rate of neurocognitive impairment than the HIV+/TB- group. HIV+/TB+ patients were more likely to be male, younger, less-educated, and have lower CD4 counts and detectable HIV RNA in blood compared with the HIV+/TB- patients. CONCLUSIONS: In HIV infection, TB may contribute to cognitive impairment, even after controlling for lower CD4 counts and viral load. Thus, systemic inflammation from HIV and TB and more advanced immune deficiency at diagnosis of HIV may contribute to impaired cognition in HIV+/TB+ patients.

Effect of age and level of education on neurocognitive impairment in HIV positive Zambian adults.

OBJECTIVE: Older age and lower education levels are known to be associated with worse neurocognitive (NC) performance in healthy adults, and individuals with HIV infection may experience accelerated brain/cognition aging. However, higher education may possibly protect against HIV-associated neurocognitive disorders (HAND). The aim of the current cross-sectional study was to assess the effect of age and education in an HIV-1 clade C infected adult population in urban Zambia. METHOD: Demographically corrected Zambian norms on a neuropsychological (NP) test battery were used to correct for normal age and education effects. The study assessed 286 HIV positive (+) males (37.1%) and females (62.9%) with a mean age of 41.35 (SD = 8.56) and mean years of education = 10.16 (SD = 2.18). A comprehensive NP test battery was used to assess cognitive domains frequently affected by HIV: attention/working memory, learning/and delayed recall, executive function, verbal fluency, processing speed, verbal and visual episodic memory, and fine motor skills. RESULTS: In younger HIV+ Zambians, higher education evidenced protective effects against NC impairments overall, and for the specific domains of executive functions, learning and speed of information processing. Impairment scores did not support accelerated overall brain aging although the restricted age range and relative youth of our total sample may have precluded detection of such tendencies. CONCLUSIONS: The present study raises the need to investigate factors that could be implicated in the poor neurocognitive performance among the younger, less educated HIV+ individuals in Zambia. (PsycINFO Database Record

The Relationships among Tryptophan, Kynurenine, Indoleamine 2,3-Dioxygenase, Depression, and Neuropsychological Performance.

It has been suggested that the metabolic enzyme indoleamine 2,3-dioxygenase (IDO) is a biological mediator of inflammation related to the psychopathology of depression, with a Kynurenine (KYN) increase in the Tryptophan (TRP) metabolic pathway, resulting in reduced Serotonin. In this study, we examined KYN, TRP, and the ratio of KYN to TRP concentrations × 103 (KT Ratio) in serum and cerebrospinal fluid (CSF) in (a) a group of depressed patients and (b) a control group of patients referred to a neurologic outpatient clinic for whom no specific diagnosis could be established. The KT Ratio is considered an index that represents IDO. The participants were examined with the Beck Depression Inventory II (BDI-II), the Montgomery Aasberg Depression Rating Scale (MADRS), and a neuropsychological test battery. We found no significant differences between the two study groups with respect to TRP, KYN, or KT Ratio in serum or CSF. Differences in neuropsychological performance between the two patient groups could be seen in the following tests: Animal Fluency, Digit Symbol, the DKEFS Color-Interference Test (Naming Part), Trail Making Test A and B, and the Grooved Pegboard Non-dominant Hand. KYN in serum correlated highly with KYN in CSF. KYN in serum correlated significantly with both age and gender. When analyzing males and females separately, we found that women had a lower level of TRP in both serum (Mann-Whitney U-test: TRP in Serum; p = 0.001) and CSF (Mann-Whitney U-test: TRP in CSF; p = 0.003). Women had a lower level of KYN in serum (p = 0.029) than men did. Age was positively associated with KYN. KYN in CSF correlated only with age, however; there were no gender differences. No significant relationship was seen between BDI-II and MADRS on the one hand, and KYN and TRP on the other. KYN in CSF as the KT Ratio in both serum and CSF was associated with neuropsychological performance. Thus, we suggest that KYN and KT Ratio are related more strongly to neuropsychological performance than to affective symptoms in depression.

Antihypertensive medication is associated with less cognitive impairment in the very old with apolipoprotein-E epsilon4 allele.

BACKGROUND AND OBJECTIVES: High and low blood pressure and apolipoprotein (Apo)-E epsilon4 alleles have been shown to be associated with dementia of the Alzheimer's type. The aim of this study was to examine the relationship between Apo-E epsilon4 allele status and the effect of antihypertensive treatment on cognitive performance in persons > or =80 years of age. METHODS: A sample of 258 individuals 80-102 years of age was studied. Associations between the Mini-Mental State Examination (MMSE) score and treatment with antihypertensive medication, blood pressure, Apo-E polymorphism, sex, age and education were assessed. Patients treated with antihypertensive drugs typically used two to ten different medications. RESULTS: Individuals with no Apo-E epsilon4 alleles who were not treated with antihypertensive medications had a significantly higher diastolic blood pressure than other participants in the study but no cognitive deficits. Participants who had at least one Apo-E epsilon4 allele who were not treated with antihypertensive medications scored significantly lower on the MMSE compared with other participants in the study. CONCLUSIONS: Individuals with an Apo-E epsilon4 allele who were not treated with antihypertensive medication showed the poorest cognitive performance. This could suggest that individuals with the Apo-E epsilon4 allele may benefit cognitively from treatment with antihypertensive drugs.

The effect of ApoE e4 on blood pressure in patients with and without depression.

INTRODUCTION: Depression is considered an independent risk factor for hypertension, particularly for people with recurrent episodes or a long history of depression. Another risk factor for cardiovascular disease is the Apolipoprotein E e4 allele (ApoE e4). The aim of this study was to examine how ApoE e4 was related to blood pressure (BP) in patients with depression and a control group. METHODS: A total of 78 patients, 49 with depression and 29 without, all recruited from the same hospital, underwent ApoE e genotyping (24 had at least one ApoE e4 allele) and examination of BP. RESULTS: In the depression group, but not in the control group, both systolic and diastolic BP were significantly higher in patients with ApoE e4 than in those without. The effect of ApoE e4 on BP differed significantly between the two groups. CONCLUSION: Our findings showed that the effect of ApoE e4 on BP differed between the patients with depression and the control group. In patients with depression, ApoE e4 was associated with an increase in BP. We suggest that patients with depression and ApoE e4-positive status are particularly prone to develop BP elevation.

Increased frontal electroencephalogram theta amplitude in patients with anorexia nervosa compared to healthy controls.

OBJECTIVE: To conduct a blind study of quantitative electroencephalogram-band amplitudes in patients with anorexia nervosa (AN) and healthy controls. METHODS: Twenty-one patients with AN and 24 controls were examined with eyes-closed 16-channel electroencephalogram. Main variables were absolute alpha, theta, and delta amplitudes in frontal, temporal, and posterior regions. RESULTS: There were no significant differences between the AN patients and controls regarding absolute regional band amplitudes in µV. Borderline significance was found for anterior theta (P=0.051). Significantly increased left and right frontal electrode theta amplitude was found in AN patients (F3, P=0.014; F4, P=0.038) compared to controls. Significant differences were also observed for secondary variables: lower values for relative parietooccipital delta and frontocentral alpha activity among AN patients than among controls. CONCLUSION: We observed slight excess frontal theta and lower relative alpha and delta amplitudes among AN patients than among controls. This pattern is possibly related to a slight frontal lobe dysfunction in AN, or it may reflect increased attention/vigilance or another state-related change in patients with AN compared to healthy controls.

HIV- and AIDS-associated neurocognitive functioning in Zambia - a perspective based on differences between the genders.

Human immunodeficiency virus (HIV) infection and acquired immune deficiency syndrome (AIDS) are frequently associated with neurocognitive impairment (NCI). However, few studies have examined the interrelationship between gender and NCI in the HIV and AIDS population. This cross-sectional study examined the neurocognitive (NC) functioning of HIV-infected male and female adults from urban Zambia. The participants included 266 HIV seropositive (HIV+) adults (males [n=107] and females [n=159]). Participants completed NC assessment by means of a comprehensive test battery using normative data from 324 HIV-seronegative (HIV-) controls. The norms corrected for effects of age, education, and gender in the general population, and the test battery measures domains of attention/working memory (learning and delayed recall), executive function, verbal fluency, processing speed, verbal and visual episodic memory, and fine motor skills. An overall comparison of the HIV+ male and female participants yielded no statistically significant differences. Analysis of covariance results controlling for disease characteristics showed that HIV+ female participants had worse delayed recall scores than males, F(1,117) =9.70, P=0.002, partial η(2)=0.077. The females also evidenced a trend toward greater impairment on learning efficiency (P=0.015). The findings suggest that there are gender-related differences in NCI after controlling for disease characteristics. It was observed that although the HIV+ females enjoyed better health compared to their HIV+ male counterparts, they still had worse performance on the neuropsychological tests. This implies that HIV may have more NC consequences for Zambian females than males.

Patients with depression display cytokine levels in serum and cerebrospinal fluid similar to patients with diffuse neurological symptoms without a defined diagnosis.

INTRODUCTION: Several reports indicate that inflammation may play a role in depression and demonstrate enhanced systemic levels of inflammatory mediators. We hypothesized that 44 patients with a diagnosis of depression would present with a specific and different serum and cerebrospinal fluid (CSF) cytokine profile compared to 21 patients with diffuse neurological symptoms, of whom 15 had fatigue as a major symptom, but no change in emotional state. METHODS: The diagnoses of the patients with depression were according to the International Classification of Diseases, tenth edition (F32-34 spectra). Cytokine profiles in serum and CSF were determined by multiplex analysis, including 27 cytokines, chemokines, and growth factors. RESULTS: No differences could be found between the two groups studied regarding cytokine levels in serum or CSF except for serum interleukin (IL)-1 receptor antagonist that was lower in the depression group. There were only four high correlations (>0.4) between serum and CSF levels of the cytokines, reflecting independent synthesis and turnover in these two compartments. In the control group, fatigue was associated with increased IL-1 receptor antagonist, IL-10, granulocyte-colony stimulating factor, and interferon-γ (all P<0.01). CONCLUSION: Patients with depression had a similar cytokine profile as nondepressive patients, both systemically and in CSF. Fatigue was associated with higher levels of some inflammatory markers in the control group. It is possible that the presence of fatigue in a large proportion of patients and controls could contribute to the lack of difference in cytokine levels between these two groups.

Do neuropsychological test norms from African Americans in the United States generalize to a Zambian population?

Healthy Zambian adults (N = 324) were evaluated to determine to what degree a Western neuropsychological (NP) test battery, with African American norms adjusted for age, gender, and education could be used in healthy Zambians, including 157 men (48.46%) and 167 women (51.54%) with an average age of 38.48 (SD = 12.80) years and an average education level of 11.02 (SD = 2.58) years. The NP battery included tests of attention/working memory, executive function, verbal fluency, processing speed, verbal and visual episodic memory, and fine motor skills. The Zambian Achievement Test (ZAT) and the U.S. Wide Range Achievement Test-4 (WRAT-4) reading subtest also were administered to assess literacy and quality of education. Similar to findings in Western countries, the Zambian results show substantial age and education effects on most tests and smaller, less consistent effects of gender. Beyond the basic demographic effects, urban/rural background had small effects on some cognitive variables, and the ZAT (but not WRAT-4) reading level was a robust predictor of performance on many NP tests, even when other background characteristics were controlled. Women in the United States tend to outperform men on tests of processing speed and episodic memory. However, Zambian women showed modest but statistically significant disadvantages versus their male counterparts. The results show that tests developed in the United States may be used in Zambia. Nevertheless, development and use of local cultural norms remains very important and is a must. New demographically corrected norms were developed for the cohort that was examined.

Predicting the clinical outcome of stimulant medication in pediatric attention-deficit/hyperactivity disorder: data from quantitative electroencephalography, event-related potentials, and a go/no-go test.

BACKGROUND: We searched for predictors of the clinical outcome of stimulant medication in pediatric attention-deficit/hyperactivity disorder (ADHD), emphasizing variables from quantitative electroencephalography, event-related potentials (ERPs), and behavioral data from a visual go/no-go test. METHODS: Nineteen-channel electroencephalography (EEG) was recorded during the resting state in eyes-open and eyes-closed conditions and during performance of the cued go/no-go task in 98 medication-naïve ADHD patients aged 7-17 years and in 90 controls with the same age and sex distribution as the patients. For patients, the recording was followed by a systematic trial on stimulant medication lasting at least 4 weeks. Based on data from rating scales and interviews, two psychologists who were blind to the electrophysiological results independently rated the patients as responders (REs) (N=74) or non-responders (non-REs) (N=24). Using a logistic regression model, comparisons were made between REs and non-REs on the EEG spectra, ERPs (cue P3, contingent negative variation, and P3 no-go of the ERP waves and independent components [ICs] extracted from these waves), reaction time, reaction time variability, number of commission and omission errors, intelligence quotient, age, sex, ADHD subtype, and comorbidities. RESULTS: The two groups differed significantly on eight of the variables, with effect sizes (Cohen's d) ranging from 0.49 to 0.76. In the multivariate logistic regression analysis, only three of these variables were significantly associated with clinical outcome. The amplitude of the IC cue P3, which has a parietal-occipital distribution, was normal in REs but significantly smaller in non-REs, whereas the centrally distributed IC P3 no-go early was smaller in REs than in non-REs and controls. In addition, the REs had more power in the EEG theta band. A quartile-based index was calculated using these three variables. The group with the lowest scores comprised only 36% REs; response rates in the three other groups were 83%, 86%, and 89%. CONCLUSION: The clinical outcome of stimulant medication was best predicted by electrophysiological parameters. The brain dysfunctions of the REs appear to be primarily associated with prefrontal lobe hypoactivation. The non-REs were deviant from the controls in parietal-occipital functions.

Effects of neurofeedback versus stimulant medication in attention-deficit/hyperactivity disorder: a randomized pilot study.

OBJECTIVE: The purpose of this pilot study was to compare the effects of 30 sessions of neurofeedback (NF) with stimulant medication on attention-deficit/hyperactivity disorder (ADHD) patients. METHODS: Thirty-two medication-naïve ADHD patients, ages 7-16, from a neuropsychiatric clinic, were randomized to NF (n=16) or drug treatment (n=16). Other actions, such as parent management training, information, or support in school were given as needed, with no differences between the groups. All participants were assessed before treatment on two rating scales, each with parent and teacher forms. In addition, quantitative electroencephalogram (QEEG) and event-related potentials (ERPs), which included behavioral data from a go/no go test were administered. NF training took place in the clinic over a period of 7-11 months, and was followed by a repeat of the same assessment tools. The mean time interval between pre- and postassesment was not significantly different in the two groups. The 18 symptoms of ADHD (American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV)) were used as the primary outcome measure. RESULTS: Analysis of covariance revealed a significant difference between the groups at evaluation in favor of medication, with a large effect size. This picture was confirmed by other outcome measures. The QEEG spectral power in the theta and beta bands did not change in either group. In ERP, the P3 no go component increased significantly in 8 of 12 patients who had a clinically relevant medication effect, but did not increase in the medication nonresponders or the NF group. CONCLUSIONS: Our study supports effects for stimulants, but not for NF. Effects of NF may require thorough patient selection, frequent training sessions, a system for excluding nonresponders, and active transfer training. The P3 no go ERP component may be a marker for treatment response.