Innovating Parkinson's Care: A Randomized Controlled Trial of Telemedicine Depression Treatment.

BACKGROUND: For several decades, a myriad of factors have contributed to the inadequate diagnosis and management of depression in Parkinson's disease (PD), leaving up to 60% of significantly symptomatic patients untreated. Poor access to evidence-based neuropsychiatric care is one major barrier to achieving optimal Parkinson's outcomes. OBJECTIVE: The goal of this study was to compare the efficacy of individual Parkinson's-informed, video-to-home cognitive-behavioral therapy (experimental group), to clinic-based treatment as usual (control group), for depression in PD. METHOD: Ninety United States military veterans with clinical diagnoses of both depression and PD were computer-randomized (1:1) to either the experimental or control group; randomization was stratified by baseline antidepressant use and blind to all other baseline data. The acute treatment period spanned 10 weeks and was followed by a 6-month extension phase. The Hamilton Depression Rating Scale was the a priori primary outcome. Depression treatment response was defined as a score ≤2 on the Clinical Global Impression Improvement Scale. All statistical analyses were intent to treat. RESULTS: Video-to-home cognitive-behavioral therapy outperformed clinic-based treatment as usual across three separate depression measures (P < 0.001). Effects were observed at the end of acute treatment and maintained through 6-month follow-up. Number needed to treat (based on treatment response classification) was 2.5 with an absolute risk reduction of 40%. CONCLUSION: Video-to-home cognitive-behavioral therapy may be an effective intervention to bypass access barriers to specialized, evidence-based depression care in PD and to address the unmet neuropsychiatric treatment needs of the Parkinson's community. © 2021 International Parkinson and Movement Disorder Society.

Cognitive behavioral therapy improves diverse profiles of depressive symptoms in Parkinson's disease.

OBJECTIVE: Depression is among the most common and debilitating nonmotor complaints in Parkinson's disease (PD), yet there is a paucity of controlled research to guide treatment. Little research has focused on the extent to which specific depressive symptom profiles may dictate unique clinical recommendations to ultimately improve treatment outcomes. The current study examined the impact of cognitive behavioral therapy (CBT) on different types of depressive symptoms in PD. It was hypothesized that the cognitive (eg, guilt, rumination, and negative attitudes towards self) and behavioral (eg, avoidance and procrastination) symptoms targeted most intensively by the treatment protocol would show the most robust response. The extent to which stabilized antidepressant use moderated specific symptom change was examined on an exploratory basis. METHOD: Eighty depressed people with PD participated in a randomized controlled trial of CBT plus clinical management, versus clinical management only. Hamilton Depression Rating Scale (HAMD) and Beck Depression Inventory (BDI) subscale scores, reflecting depressive symptom heterogeneity in PD, were the focus of this investigation. RESULTS: CBT response was associated with significant improvements in mood, sleep, anxiety, and somatic symptoms (HAMD), and negative attitudes toward self, performance impairment, and somatic symptoms (BDI). As hypothesized, the largest effect sizes were observed for cognitive and behavioral (vs somatic) symptoms of depression. Stabilized antidepressant use moderated the effect of CBT on somatic complaints (HAMD and BDI). CONCLUSIONS: CBT may improve a diverse array of depressive symptoms in PD. Cognitive and behavioral (vs somatic) symptoms showed the greatest change. Combining CBT with antidepressants may help optimize the management of somatic complaints in depression in PD (dPD).

Personalized Telemedicine for Depression in Parkinson's Disease: A Pilot Trial.

High rates of depression are observed in Parkinson's disease, and limited access to care complicates management. The purpose of this pilot project was to evaluate the feasibility and impact of a personalized cognitive-behavioral telemedicine program for depression in Parkinson's disease (dPD). Thirty-four individuals with dPD and their carepartners participated in this pilot study. A 10-module self-help workbook, tailored to the unique needs of the dPD population, was created to be used as either a stand-alone intervention, with minimal therapist support, or a supplement to formal telephone-administered cognitive-behavioral therapy sessions. Improvements in depression, anxiety, quality of life, sleep, negative thoughts, and caregiver burden were observed over the course of the 4-month study, independent of treatment modality (guided self-help vs formal telephone-based psychotherapy). Future research will utilize randomized controlled designs and continue to focus on delivery models that can improve access to this and other evidence-based mental health interventions for dPD.

Multifocal necrotising leucoencephalopathy following Salmonella infection in an immunocompetent patient.

Multifocal necrotising leucoencephalopathy is a rare disorder affecting the central nervous system. It is characterised pathologically by microscopic areas of necrosis with pontine predilection but also involvement of extrapontine regions, including the cerebellum, medulla and cerebral hemispheres. It usually occurs on the background of immunosuppression. Here we describe an immunocompetent patient with a recent history of Salmonella infection who presented with subacute neurological deterioration. At postmortem, she had evidence of multifocal necrotising leucoencephalopathy.

Neuropsychological outcomes after psychosocial intervention for depression in Parkinson's disease.

The authors describe neuropsychological outcomes in people with Parkinson's disease (PD) after their participation in an NIH-sponsored, randomized, controlled trial of cognitive-behavioral treatment for depression. Improvements in mood were associated with modest gains in verbal memory and executive functioning over the 10-week treatment period and accounted for greater variance in neuropsychological outcomes at the end of treatment than other known correlates of cognitive functioning in PD, such as disease severity, age, and education. Baseline working memory and executive skills were also associated with depression improvement over time.

A randomized-controlled trial of an intervention to improve antidepressant adherence among Latinos with depression.

BACKGROUND: Studies have consistently shown that Latinos with depression have lower adherence to antidepressant medication. Given that low adherence is associated with poorer response to treatment, this is a likely source of unequal care. The current study examined the efficacy of a motivational interviewing intervention for improving antidepressant adherence among Latinos with a depressive disorder. METHODS: Participants were 50 Latinos with a DSM-IV diagnosis of major depression or dysthymia who were receiving treatment at a community mental health center. Participants were recruited from July 2007 to December 2009 and were randomized to receive usual care (UC) or Motivational Enhancement Therapy for Antidepressants (META). META participants received three sessions of motivational interviewing as an enhancement to their usual care. Participants were assessed as baseline (time 1), 5 weeks (time 2), and 5 months (time 3). Antidepressant adherence was measured with the Medication Event Monitoring System (MEMS®) and changes in depression were measured with the Beck Depression Inventory-II (BDI-II). RESULTS: After adjusting for covariates, META participants showed significantly higher antidepressant adherence than UC participants at time 2 (72% versus 42%, respectively, p < .01) and time 3 (60% versus 34%, p < .01). The groups did not differ on mean BDI-II score across time. However, after adjusting for covariates, META participants were significantly more likely to show symptom remission on the BDI-II, compared to UC participants (OR = 7.0, p < .05). CONCLUSIONS: This initial trial of META demonstrated feasibility and promising effects for improving antidepressant adherence. Some effects on depression were also observed.

Barriers to mental health care utilization in Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) is frequently complicated by co-occurring psychiatric problems such as depression and anxiety that negatively affect the course and management of the illness. Yet, in most cases, these psychiatric comorbidities are neither recognized nor treated to remission. The primary purpose of this study was to identify and describe barriers to mental health care utilization for people with PD. Secondary objectives included the assessment of attitudes and preferences regarding the need for mental health services in the PD community and the acceptability of telehealth interventions as a method for improving access and quality of care. METHODS: A total of 769 people with PD completed an anonymous cross-sectional questionnaire assessing barriers to mental health care utilization in this medical population. Respondents were drawn from a national sample. RESULTS: Commonly endorsed barriers to mental health care utilization in PD reflect the patients' incomplete understanding of mental health problems, access issues, and illness-specific concerns, as well as the inadequate screening and detection of psychiatric complications by medical providers and the need for more effective treatments in this medical population. Several demographic, medical, and psychiatric variables also influenced the likelihood of accessing mental health care. Interest in telehealth approaches to mental health treatment was high and, in several instances, correlated with perceived barriers to mental health care utilization. CONCLUSIONS: People with PD may encounter a multitude of barriers that impede their pursuit of mental health care. Clinical implications are discussed and further research is needed to replicate and extend these findings.

Telephone-based cognitive-behavioral therapy for depression in Parkinson disease.

BACKGROUND: Although face-to-face cognitive-behavioral therapy (CBT) was found to be beneficial for the treatment of depression in Parkinson disease (dPD) in a recent randomized-controlled trial, access to care was identified as a critical issue that needs to be addressed in order to improve the management of this nonmotor complication in PD. The purpose of this study was to examine the feasibility and effect of telephone-based CBT for dPD. METHODS: Twenty-one depressed people with PD participated in a National Institutes of Health-sponsored uncontrolled pilot trial of telephone-based CBT in an academic medical center from October 2009 to February 2011. The Hamilton Depression Rating Scale was the primary outcome. Treatment was provided to people with PD for 10 weeks, modified for delivery over the phone, and supplemented with 4 separate phone-based caregiver educational sessions. Assessments were completed at baseline and 5 (midpoint), 10 (end-of-treatment), and 14 weeks (follow-up) post-enrollment. RESULTS: Twenty (95%) people with PD completed the study treatment. Phone-based CBT was associated with significant improvements in depression, anxiety, negative thoughts, and coping. Mean Hamilton Depression Rating Scale change from baseline to week 10 was 7.91 points (P < .001, Cohen d = 1.21). CONCLUSIONS: Telephone-based CBT may be a feasible and helpful approach for treating dPD and warrants further exploration in randomized-controlled trials. Results were comparable to those observed in the few in-person cognitive-behavioral treatment studies for dPD conducted to date.

Psychophysiologic treatment for patients with medically unexplained symptoms: a randomized controlled trial.

BACKGROUND: Patients presenting with medically unexplained physical symptoms (MUPS) typically present with significant distress and marked impairment in functioning and pose a unique challenge to health care providers. The purpose of this study was to examine the efficacy of a psychophysiological treatment (PT) for MUPS. METHODS: Thirty-eight participants meeting criteria for subthreshold somatization disorder (abridged somatization) were randomly assigned to one of two conditions: (1) standard medical care augmented by a psychiatric consultation intervention (wait-list) or (2) a 10-session, manualized, individually-administered PT added to the psychiatric consultation intervention. Assessments were conducted at baseline, at midpoint (after four sessions), and after completing the last session. The primary outcome measure was the severity scale of the Clinical Global Impression Scale anchored for Somatic Symptoms (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-report measures of mental and physical functioning. RESULTS: At the end of the trial, the severity (and frequency) of physical symptoms improved significantly more (p<0.05) in the intervention group. The average improvement in the CGI-SD was 0.80 points greater in the intervention group than in the wait-list group. PT was also associated with greater improvements in self-reported functioning and depressive symptomatology. The effect sizes at the final assessment point indicate that this intervention had a robust effect on complex somatic symptom presentations. CONCLUSION: For patients with high levels of MUPS (abridged somatization), PT produces significant improvements in symptoms and functional status.

The role of complex emotions in inconsistent diagnoses of schizophrenia.

In the case of large-scale epidemiological studies, there is evidence of substantial disagreement when lay diagnoses of schizophrenia based on structured interviews are compared with expert diagnoses of the same patients. Reasons for this level of disagreement are investigated in the current study, which made use of advances in text-mining techniques and associated structural representations of language expressions. Specifically, the current study examined whether content analyses of transcribed diagnostic interviews obtained from 150 persons with serious psychiatric disorders yielded any discernable patterns that correlated with diagnostic inconsistencies of schizophrenia. In summary, it was found that the patterning or structure of spontaneous self-reports of emotion states in the diagnostic interview was associated with diagnostic inconsistencies of schizophrenia, irrespective of confounders; i.e., age of patient, gender, or ethnicity. In particular, complex emotion patterns were associated with greater disagreement between experts and trained lay interviewers than were simpler patterns.

Telephone-based cognitive behavioral therapy for depression in Parkinson disease: A randomized controlled trial.

OBJECTIVE: To determine whether, for patients with depression and Parkinson disease (PD), telephone-based cognitive-behavioral treatment (T-CBT) alleviates depressive symptoms significantly more than treatment as usual (TAU), we conducted a randomized controlled trial to evaluate the efficacy of a 10-session T-CBT intervention for depression in PD, compared to TAU. METHODS: Seventy-two people with PD (PWP) were randomized to T-CBT + TAU or TAU only. T-CBT tailored to PWPs' unique needs was provided weekly for 3 months, then monthly during 6-month follow-up. CBT targeted negative thoughts (e.g., "I have no control"; "I am helpless") and behaviors (e.g., social withdrawal, excessive worry). It also trained care partners to help PWP practice healthy habits. Blind raters assessed outcomes at baseline, midtreatment, treatment end, and 1 and 6 months post-treatment. Analyses were intent to treat. RESULTS: T-CBT outperformed TAU on all depression, anxiety, and quality of life measures. The primary outcome (Hamilton Depression Rating Scale score) improved significantly in T-CBT compared to TAU by treatment end. Mean improvement from baseline was 6.53 points for T-CBT and -0.27 points for TAU (p < 0.0001); gains persisted over 6-month follow-up (p < 0.0001). Improvements were moderated by a reduction in negative thoughts in the T-CBT group only, reflecting treatment target engagement. CONCLUSIONS: T-CBT may be an effective depression intervention that addresses a significant unmet PD treatment need and bypasses access barriers to multidisciplinary, evidence-based care. CLINICALTRIALSGOV IDENTIFIER: NCT02505737. CLASSIFICATION OF EVIDENCE: This study provides Class I evidence that for patients with depression and PD, T-CBT significantly alleviated depressive symptoms compared to usual care.

Towards the objective assessment of suicidal states: Some neurocognitive deficits may be temporally related to suicide attempt.

Neurocognitive detection of suicidal states has the potential to significantly advance objective risk assessment. This goal requires establishing that neurocognitive deficits fluctuate around the time of a suicide attempt. The current study therefore evaluated whether neurocognitive performance is temporally related to suicide attempt, in a sample at highrisk for suicide (n = 141). Evaluations consisted of a clinician-administered interview, self-report questionnaires, and neurocognitive tasks assessing response inhibition, attentional control, and memory recognition. Analyses examined whether neurocognitive scores significantly differed according to the following temporal suicide attempt categories: (a) past-week attempt; (b) past-year attempt (not in past week); and (c) no past-year attempt. Univariate results showed that response inhibition and memory recognition were significantly related to suicide attempt recency. Post-hoc pairwise tests showed that participants with a past-week suicide attempt showed greater impairments than those without a past-year attempt. Multivariate tests showed the same pattern of results, adjusting for age, suicide attempts prior to past year, mood disturbance, and suicidal ideation. These results show that neurocognitive assessment of response inhibition and memory recognition shows sensitivity to the recency of a suicide attempt. While future prospective studies are needed, results suggest that phasic neurocognitive deficits may serve as objective markers of short-term suicide risk.

A Naturalistic Study of Racial Disparities in Diagnoses at an Outpatient Behavioral Health Clinic.

OBJECTIVE: The authors examined electronic medical record (EMR) outpatient data to determine whether African Americans with schizophrenia or schizoaffective disorder were more likely than non-Latino whites to screen positive for major depression. METHODS: EMR data for 1,657 patients at Rutgers University Behavioral Health Care certified community outpatient clinics were deidentified and accrued for 9 months starting July 1, 2017. A Fisher's exact test was used to compare differences in the proportion of patients with positive screens for major depression (cutoff score of ≥15 on the nine-item Patient Health Questionnaire) among African-American and non-Latino white patients diagnosed as having schizophrenia or schizoaffective disorder. RESULTS: Among patients diagnosed as having schizophrenia, African Americans were more likely than non-Latino whites (p<.003) to screen positive for major depression. The between-group difference in positive screens was not significant among patients diagnosed as having schizoaffective disorder. CONCLUSIONS: The results are consistent with findings from a large body of literature suggesting that racial differences in the diagnosis of schizophrenia in the United States result in part from clinicians underemphasizing the relevance of mood symptoms among African Americans compared with other racial-ethnic groups. If the results are replicated, a case could be made that routine screening for major depression in community mental health settings could reduce racial disparities in schizophrenia diagnoses.

Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms.

PURPOSE: Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients. METHODS: We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care. RESULTS: A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as "very much improved" or "much improved" compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9-8.8; P<.001). The intervention's effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up. CONCLUSIONS: This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Cognitive-behavioral therapy for somatization disorder: a randomized controlled trial.

BACKGROUND: Patients diagnosed as having somatization disorder (SD) who present with a lifetime history of multiple, medically unexplained physical symptoms represent a significant challenge to health care providers. To date, no psychotherapeutic or pharmacologic intervention has been found to produce clinically meaningful improvement in symptoms or functioning of patients with SD. We examined the efficacy of cognitive-behavioral therapy (CBT) for SD. METHODS: Eighty-four participants meeting criteria for SD were randomly assigned to 1 of 2 conditions: (1) standard medical care augmented by a psychiatric consultation intervention or (2) a 10-session, manualized, individually administered CBT regimen added to the psychiatric consultation intervention. Assessments were conducted at baseline and 3, 9, and 15 months after baseline. The primary outcome measure was the severity scale of the Clinical Global Impression Scale for Somatization Disorder (CGI-SD). Secondary outcome measures were responder status as determined by clinical ratings, self-reported measures of physical functioning and somatic symptoms, and health care utilization assessed via medical records. RESULTS: Fifteen months after baseline, somatization symptoms were significantly less severe in the group treated with CBT (0.84 points on the CGI-SD 7-point scale) (P<.001). Patients treated with CBT also were significantly more likely to be rated as either very much improved or much improved than patients treated with only augmented standard medical care (40% [n = 17] vs 5% [n = 2]). Cognitive-behavioral therapy was associated with greater improvements in self-reported functioning and somatic symptoms and a greater decrease in health care costs. CONCLUSION: For patients diagnosed as having SD, CBT may produce clinical benefits beyond those that result from the current state-of-the-art treatment.

Hierarchical Classes Analysis (HICLAS): A novel data reduction method to examine associations between biallelic SNPs and perceptual organization phenotypes in schizophrenia.

The power of SNP association studies to detect valid relationships with clinical phenotypes in schizophrenia is largely limited by the number of SNPs selected and non-specificity of phenotypes. To address this, we first assessed performance on two visual perceptual organization tasks designed to avoid many generalized deficit confounds, Kanizsa shape perception and contour integration, in a schizophrenia patient sample. Then, to reduce the total number of candidate SNPs analyzed in association with perceptual organization phenotypes, we employed a two-stage strategy: first a priori SNPs from three candidate genes were selected (GAD1, NRG1 and DTNBP1); then a Hierarchical Classes Analysis (HICLAS) was performed to reduce the total number of SNPs, based on statistically related SNP clusters. HICLAS reduced the total number of candidate SNPs for subsequent phenotype association analyses from 6 to 3. MANCOVAs indicated that rs10503929 and rs1978340 were associated with the Kanizsa shape perception filling in metric but not the global shape detection metric. rs10503929 was also associated with altered contour integration performance. SNPs not selected by the HICLAS model were unrelated to perceptual phenotype indices. While the contribution of candidate SNPs to perceptual impairments requires further clarification, this study reports the first application of HICLAS as a hypothesis-independent mathematical method for SNP data reduction. HICLAS may be useful for future larger scale genotype-phenotype association studies.

The value of pseudoneurological symptoms for assessing psychopathology in primary care.

OBJECTIVE: This study sought to examine the relationship between pseudoneurological symptoms (PNS) and somatic and psychiatric symptom severity, physical functioning, and psychiatric comorbidity. METHODS: Interview and questionnaire data were obtained from 120 patients with somatization who participated in a study assessing the efficacy of cognitive-behavioral therapy. Measures elicited information on psychiatric diagnoses, anxiety and depressive symptom levels, somatic symptoms, and physical functioning. Statistical analyses examined the relationship between PNS and the diagnosis of somatization disorder, physical and psychiatric symptom severity, and psychiatric comorbidity. RESULTS: Roughly half of the sample had a history of four or more PNS. Results showed that having four or more PNS was not predictive of somatization disorder. However, having four or more PNS was found to be significantly correlated with the severity of anxiety, depression, somatic complaints, and physical dysfunction. These associations were identified while controlling for the symptom count of nonpseudoneurological symptoms, the presence of somatization disorder, and the presence of chronic painful physical conditions. In addition, having four or more PNS was significantly associated with a higher likelihood of receiving a diagnosis of major depression, dysthymia, panic disorder, and generalized anxiety disorder. CONCLUSIONS: A history of four or more PNS is common among somatizing patients in primary care and associated with a more severe clinical presentation, even after controlling for other factors known to be associated with severity. Four or more PNS may identify a distinct subgroup of somatization and serve as a clinical indicator for identifying psychiatric disorders in primary care. Future studies should explore the assessment of PNS using briefer measures. Furthermore, PNS should be evaluated with samples more representative of US primary care populations, as well as samples that include adequate representation from other ethnic backgrounds (eg, African-American, Asian, etc.).

Is disorganization a feature of schizophrenia or a modifying influence: evidence of covariation of perceptual and cognitive organization in a non-patient sample.

A subgroup of people with schizophrenia is characterized by reduced organization in perception, thought, language, and motor functioning, and these impairments covary significantly. While this may reflect multiple expressions of an illness-related core processing impairment, it may also represent the extreme end of an organization-disorganization dimension that is found throughout the general population. In this view, disorganization is a modifying influence on illness expression. To obtain preliminary information on this hypothesis, we examined covariation of perceptual and cognitive organization in a non-patient sample. Subjects completed a battery of perceptual tasks with demonstrated sensitivity to schizophrenia and disorganization, and a battery of questionnaires examining cognitive organization. Our results indicated that level of perceptual organization ability, across multiple tasks, was associated with self-reported levels of cognitive organization on multiple measures. This is thus preliminary evidence for a common process affecting perceptual and cognitive organization in the general population, suggesting that disorganization may reflect a modifying influence mechanism, instead of an illness-related process, in schizophrenia.

Predictors of treatment response to cognitive-behavioral therapy for depression in Parkinson's disease.

OBJECTIVE: The purpose of this study was to examine predictors of treatment response to cognitive-behavioral therapy (CBT) for depression in Parkinson's disease (PD). METHOD: The sample comprised 80 depressed (DSM-IV criteria) adults with PD (60% male) and their caregivers who participated in an National Institutes of Health-sponsored randomized-controlled trial of CBT vs. clinical monitoring from April 2007 until July 2010. Individually administered CBT was provided to people with PD for 10 weeks, modified to address the unique needs of the medical population, and supplemented with up to 4 separate caregiver educational sessions. Treatment response was defined a priori as a rating of depression much improved or very much improved on the Clinical Global Impression-Improvement Scale or ≥ 50% reduction in the baseline Hamilton Depression Rating Scale score. It was hypothesized (a priori) that caregiver participation in treatment, motor disability, psychiatric comorbidity, and executive functioning would be significant predictors of response to CBT at end-of-treatment (Week 10) and short-term follow-up (Week 14). RESULTS: At Week 10, caregiver participation was the only significant predictor of treatment response in the CBT group. At Week 14, both caregiver participation and executive functioning predicted response to CBT. Treatment group, baseline depression severity, executive functioning, motor disability, psychiatric comorbidity, marital status, and caregiver burden were also related to change in depression scores, for all participants, in secondary and exploratory models. CONCLUSIONS: Caregiver participation may enhance acute treatment response to psychosocial interventions for depression in PD. Further research is needed to extend and replicate these findings.

Influence of patient race and ethnicity on clinical assessment in patients with affective disorders.

CONTEXT: Rates of clinical diagnoses of schizophrenia in African American individuals appear to be elevated compared with other ethnic groups in the United States, contradicting population rates derived from epidemiologic surveys. OBJECTIVE: To determine whether African American individuals would continue to exhibit significantly higher rates of clinical diagnoses of schizophrenia, even after controlling for age, sex, income, site, and education, as well as the presence or absence of serious affective disorder, as determined by experts blinded to race and ethnicity. A secondary objective was to determine if a similar pattern occurred in Latino subjects. DESIGN: Ethnicity-blinded and -unblinded diagnostic assessments were obtained in 241 African American individuals (mean [SD] age, 34.3 [8.1] years; 57% women), 220 non-Latino white individuals (mean [SD] age, 32.7 [8.5] years; 53% women), and 149 Latino individuals (mean [SD] age, 33.5 [8.0] years; 58% women) at 6 US sites. Logistic regression models were used to determine whether elevated rates of schizophrenia in African American individuals would persist after controlling for various confounding variables including blinded expert consensus diagnoses of serious affective illness. SETTINGS: Six academic medical centers across the United States. PARTICIPANTS: Six hundred ten psychiatric inpatients and outpatients. MAIN OUTCOME MEASURE: Relative odds of unblinded clinical diagnoses of schizophrenia in African American compared with white individuals. RESULTS: A significant ethnicity/race effect (χ(2)(2)=10.4, P=.01) was obtained when schizophrenia was narrowly defined, controlling for all other predictors. The odds ratio comparing African American with non-Latino white individuals was significant (odds ratio=2.7; 95% CI, 1.5-5.1). Similar differences between African American and white individuals occurred when schizophrenia was more broadly defined (odds ratio=2.5; 95% CI, 1.4-4.5). African American individuals did not differ significantly from white individuals in overall severity of manic and depressive symptoms but did evidence more severe psychosis. CONCLUSIONS: African American individuals exhibited significantly higher rates of clinical diagnoses of schizophrenia than non-Latino white subjects, even after controlling for covariates such as serious affective disorder.