Reliable change in neuropsychological assessment of breast cancer survivors.

BACKGROUND: The purpose of this study was to enhance the current understanding and interpretation of longitudinal change on tests of neurocognitive function in individuals with cancer. Scores on standard neuropsychological instruments may be impacted by practice effects and other random forms of error. METHODS: The current study assessed the test-retest reliability of several tests and overarching cognitive domains comprising a neurocognitive battery typical of those used for research and clinical evaluation using relevant time frames. Practice effect-adjusted reliable change confidence intervals for test-retest difference scores based on a sample of patient-matched healthy controls are provided. RESULTS: By applying reliable change confidence intervals to scores from two samples of breast cancer patients at post-treatment follow-up assessment, meaningful levels of detectable change in cognitive functioning in breast cancer survivors were ascertained and indicate that standardized neuropsychological instruments may be subject to limitations in detection of subtle cognitive dysfunction over clinically relevant intervals, especially in patient samples with average to above average range baseline functioning. CONCLUSIONS: These results are discussed in relation to reported prevalence of cognitive change in breast cancer patients along with recommendations for study designs that enhance detection of treatment effects.

Early Childhood Adversity and its Associations With Anxiety, Depression, and Distress in Women With Breast Cancer.

BACKGROUND: Certain vulnerability factors have been found to place patients at risk for depression and anxiety, especially within the context of medical illness. OBJECTIVES: We sought to describe the relationships among early childhood adversity (ECA) and anxiety, depression and distress in patients with breast cancer. METHODS: Patients with breast cancer (stages 0-IV) were assessed for ECA (i.e., the Risky Families Questionnaire subscales include Abuse/Neglect/Chaotic Home Environment), distress (i.e., Distress Thermometer and Problem List), anxiety (Hospital Anxiety and Depression Scale-Anxiety), depression (Hospital Anxiety and Depression Scale-Depression), meeting standardized cut-off thresholds for distress (Distress Thermometer and Problem List ≥4 or ≥7)/anxiety (Hospital Anxiety and Depression Scale-Anxiety ≥8)/depression (Hospital Anxiety and Depression Scale-Depression ≥8) and demographic factors. RESULTS: A total of 125 participants completed the study (78% response rate). ECA was associated with depression (p <0.001), anxiety (p = 0.001), and distress (p = 0.006), meeting cut-off threshold criteria for distress (p = 0.024), anxiety (p = 0.048), and depression (p = 0.001). On multivariate analysis, only depression (p = 0.04) and emotional issues (i.e., component of Distress Thermometer and Problem List) (p = 0.001) were associated with ECA. Neglect, but not Abuse and Chaotic Home Environment, was associated with depression (ß = 0.442, p < 0.001), anxiety (ß = 0.342, p = 0.002), and self-identified problems with family (ß = 0.288, p = 0.022), emotion (ß = 0.345, p = 0.004), and physical issues (ß = 0.408, p < 0.001). CONCLUSION: ECA and neglect are associated with multiple psychologic symptoms, but most specifically depression in the setting of breast cancer. ECA contributes to psychologic burden as a vulnerability factor. ECA may help to explain individual patient trajectories and influence the provision of patient-centered care for psychologic symptoms in patients with breast cancer.

Learning and memory performance in a cohort of clinically referred breast cancer survivors: the role of attention versus forgetting in patient-reported memory complaints.

OBJECTIVE: While forgetfulness is widely reported by breast cancer survivors, studies documenting objective memory performance yield mixed, largely inconsistent, results. Failure to find consistent, objective memory issues may be due to the possibility that cancer survivors misattribute their experience of forgetfulness to primary memory issues rather than to difficulties in attention at the time of learning. METHODS: To clarify potential attention issues, factor scores for Attention Span, Learning Efficiency, Delayed Memory, and Inaccurate Memory were analyzed for the California Verbal Learning Test-Second Edition (CVLT-II) in 64 clinically referred breast cancer survivors with self-reported cognitive complaints; item analysis was conducted to clarify specific contributors to observed effects, and contrasts between learning and recall trials were compared with normative data. Performance on broader cognitive domains is also reported. RESULTS: The Attention Span factor, but not Learning Efficiency, Delayed Memory, or Inaccurate Memory factors, was significantly affected in this clinical sample. Contrasts between trials were consistent with normative data and did not indicate greater loss of information over time than in the normative sample. CONCLUSIONS: Results of this analysis suggest that attentional dysfunction may contribute to subjective and objective memory complaints in breast cancer survivors. These results are discussed in the context of broader cognitive effects following treatment for clinicians who may see cancer survivors for assessment.

Cancer, coping, and cognition: a model for the role of stress reactivity in cancer-related cognitive decline.

BACKGROUND: Cognitive decline and accompanying neurological changes associated with non-CNS cancer diagnosis and treatment have been increasingly identified in a subset of patients. Initially believed to be because of neurotoxic effects of chemotherapy exposure, observation of cognitive decline in patients not treated with chemotherapy, cancer-diagnosed individuals prior to treatment, and patients receiving alternative treatment modalities (surgery, endocrine therapy, and radiation) has led to the investigation of additional potential etiologies and moderating factors. Stressful experiences have long been posited as a contributor to these cognitive changes. Through reciprocal connectivity with peripheral systems, the brain maintains a dynamic circuitry to adapt to stress (allostasis). However, overuse of this system leads to dysregulation and contributes to pathophysiology (allostatic load). At this time, little research has been conducted to systematically examine the role of allostatic load in cancer-related cognitive dysfunction. METHODS AND RESULTS: Here, we integrate theories of stress biology, neuropsychology, and coping and propose a model through which individuals with a high level of allostatic load at diagnosis may be particularly vulnerable to the neurocognitive effects of cancer. CONCLUSIONS: Opportunities for future research to test and extend proposed mechanisms are discussed in addition to points of prevention and intervention based on individual variation in stress reactivity and coping skills.

The level of association between functional performance status measures and patient-reported outcomes in cancer patients: a systematic review.

PURPOSE: The process of assessing patient symptoms and functionality using patient-reported outcomes (PROs) and functional performance status (FPS) is an essential aspect of patient-centered oncology research and care. However, PRO and FPS measures are often employed separately or inconsistently combined. Thus, the purpose of this study was to conduct a systematic review of the level of association between PRO and FPS measures to determine their differential or combined utility. METHODS: A systematic search was conducted using five databases (1966 to February 2014) to identify studies that described an association between PRO and FPS. Studies were excluded if they were non-cancer specific, did not include adults aged 18 or older, or were review articles. Publications were selected for review by consensus among two authors, with a third author arbitrating as needed. RESULTS: A total of 18 studies met inclusion criteria. FPS was primarily assessed by clinicians using the ECOG Performance Status or Karnofsky Performance Status measures. PROs were captured using a variety of measures, with numerous domains assessed (e.g., pain, fatigue, and general health status). Concordance between PROs and FPS measures was widely variable, falling in the low to moderate range (0.09-0.72). CONCLUSIONS: Despite consistency in the method of capture of PROs or FPS, domain capture varied considerably across reviewed studies. Irrespective of the method of capturing PROs or FPS, the quantified level of association between these two areas was moderate at best, providing evidence that FPS and PRO assessments offer unique information to assist clinicians in their decision-making.

Mother-daughter communication about breast cancer risk: interpersonal and biological stress processes.

Women with a personal or maternal history of breast cancer experience psychological stress in relation to breast cancer risk, and adolescent and young adult daughters are particularly at risk for experiencing stress related to their mothers' history of breast cancer. The current study examined interpersonal and biological stress responses during a laboratory-based communication task about breast cancer risk in 32 mother-daughter dyads and explores whether certain communication styles between mothers and daughters are associated with increased stress reactivity during the task. Five saliva samples were collected from each participant to determine cortisol baseline levels, reactivity to, and recovery from the task. Negative maternal communication was associated with higher cortisol levels in daughters. In addition, maternal sadness was correlated with lower levels of daughters' cortisol at all time points with the exception of baseline measures. Implications for understanding the psychobiology of stress in women at risk for breast cancer are highlighted.

A quantitative meta-analysis of neurocognitive sequelae in survivors of pediatric brain tumors.

BACKGROUND: Deficits in neurocognitive functioning are an important area of late effects in survivors of pediatric brain tumors, but a quantitative analysis of the magnitude of these deficits has yet to be conducted. PROCEDURE: The purpose of the current article is to provide a comprehensive meta-analysis of the literature on long-term neurocognitive effects found in these survivors. RESULTS: Results indicated significant deficits in both narrow and broad indices of neurocognitive functioning, and the overall magnitude of the effects across all domains ranged from small to large in magnitude (g = -0.45 to -1.43) with a large mean overall effect size of g = -0.91. CONCLUSIONS: These findings underscore the importance of monitoring the neurocognitive late effects in survivors of pediatric brain tumors, and the need for more consistent consideration of demographic, diagnostic, and treatment-related variables in future research to allow for examination of factors that may moderate these deficits.

Diagnostic Associations of Processing Speed in a Transdiagnostic, Pediatric Sample.

INTRODUCTION: The present study examines the relationships between processing speed (PS), mental health disorders, and learning disorders. Prior work has tended to explore relationships between PS deficits and specific diagnoses in isolation of one another. Here, we simultaneously investigated PS associations with five diagnoses (i.e., anxiety, autism, ADHD, depressive, specific learning) in a large-scale, transdiagnostic, community self-referred sample. METHOD: 843 children, ages 8-16 were included from the Healthy Brain Network (HBN) Biobank. Principal component analysis (PCA) was employed to create a composite measure of four PS tasks, referred to as PC1. Intraclass correlation coefficient (ICC) between the four PS measures, as well as PC1, were calculated to assess reliability. RESULTS: ICCs were moderate between WISC-V tasks (0.663), and relatively modest between NIH Toolbox Pattern Comparison and other PS scales (0.14-0.27). Regression analyses revealed specific significant relationships between PS and reading and math disabilities, ADHD-inattentive presentation (ADHD-I), and ADHD-combined presentation (ADHD-C). After accounting for inattention, the present study did not find a significant relationship with Autism Spectrum Disorder. DISCUSSION: Our examination of PS in a large, transdiagnostic sample suggested more specific associations with ADHD and learning disorders than the literature currently suggests. Implications for understanding how PS interacts with a highly heterogeneous childhood sample are discussed.

Development of Three Web-Based Computerized Versions of the Kiddie Schedule for Affective Disorders and Schizophrenia Child Psychiatric Diagnostic Interview: Preliminary Validity Data.

OBJECTIVE: To present initial validity data on three web-based computerized versions of the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS-COMP). METHOD: The sample for evaluating the validity of the clinician-administered KSADS-COMP included 511 youths 6-18 years of age who were participants in the Child Mind Institute Healthy Brain Network. The sample for evaluating the parent and youth self-administered versions of the KSADS-COMP included 158 youths 11-17 years of age recruited from three academic institutions. RESULTS: Average administration time for completing the combined parent and youth clinician-administered KSADS-COMP was less time than previously reported for completing the paper-and-pencil K-SADS with only one informant (91.9 ± 50.1 minutes). Average administration times for the youth and parent self-administered KSADS-COMP were 50.9 ± 28.0 minutes and 63.2 ± 38.3 minutes, respectively, and youths and parents rated their experience using the web-based self-administered KSADS-COMP versions very positively. Diagnoses generated with all three KSADS-COMP versions demonstrated good convergent validity against established clinical rating scales and dimensional diagnostic-specific ratings derived from the KSADS-COMP. When parent and youth self-administered KSADS-COMP data were integrated, good to excellent concordance was also achieved between diagnoses derived using the self-administered and clinician-administered KSADS-COMP versions (area under the curve = 0.89-1.00). CONCLUSION: The three versions of the KSADS-COMP demonstrate promising psychometric properties, while offering efficiency in administration and scoring. The clinician-administered KSADS-COMP shows utility not only for research, but also for implementation in clinical practice, with self-report preinterview ratings that streamline administration. The self-administered KSADS-COMP versions have numerous potential research and clinical applications, including in large-scale epidemiological studies, in schools, in emergency departments, and in telehealth to address the critical shortage of child and adolescent mental health specialists. CLINICAL TRIAL REGISTRATION INFORMATION: Computerized Screening for Comorbidity in Adolescents With Substance or Psychiatric Disorders; https://clinicaltrials.gov/; NCT01866956.

Do comorbid anxiety disorders impact treatment planning for outpatients with major depressive disorder?

Research indicates that depressed patients with comorbid anxiety disorders have a poorer long-term course of illness, are less responsive to treatment, and may experience greater deficits in psychosocial functioning, when compared with depressed patients without comorbid anxiety disorders. The objective of this study was to examine, through use of a large, well-characterized clinical database, how clinicians may modify treatment recommendations in depressed outpatients when anxiety disorders are present. A group of 346 case records, derived from the Methods to Improve Diagnostic Assessment and Services (MIDAS) project at Rhode Island Hospital, were examined to determine what treatment recommendations were made immediately after diagnosis. Psychopharmacological and psychotherapeutic treatments were classified to capture differences in recommendations between groups. Demographic and clinical characteristics were compared for patients with (n=248) and without (n=98) comorbid anxiety disorders. Utilizing logistic regression models, we found patients with anxiety disorders had a greater number of psychopharmacological therapies included as part of their initial treatment plan, but no differences were found in initial psychotherapeutic interventions. Our results indicate that practitioners are making unique recommendations based on comorbid anxiety diagnoses, but outcome studies are now needed to determine the most effective treatment methods for this patient population.

An open resource for transdiagnostic research in pediatric mental health and learning disorders.

Technological and methodological innovations are equipping researchers with unprecedented capabilities for detecting and characterizing pathologic processes in the developing human brain. As a result, ambitions to achieve clinically useful tools to assist in the diagnosis and management of mental health and learning disorders are gaining momentum. To this end, it is critical to accrue large-scale multimodal datasets that capture a broad range of commonly encountered clinical psychopathology. The Child Mind Institute has launched the Healthy Brain Network (HBN), an ongoing initiative focused on creating and sharing a biobank of data from 10,000 New York area participants (ages 5-21). The HBN Biobank houses data about psychiatric, behavioral, cognitive, and lifestyle phenotypes, as well as multimodal brain imaging (resting and naturalistic viewing fMRI, diffusion MRI, morphometric MRI), electroencephalography, eye-tracking, voice and video recordings, genetics and actigraphy. Here, we present the rationale, design and implementation of HBN protocols. We describe the first data release (n=664) and the potential of the biobank to advance related areas (e.g., biophysical modeling, voice analysis).

Learning and memory performance in breast cancer survivors 2 to 6 years post-treatment: the role of encoding versus forgetting.

PURPOSE: Our previous retrospective analysis of clinically referred breast cancer survivors' performance on learning and memory measures found a primary weakness in initial encoding of information into working memory with intact retention and recall of this same information at a delay. This suggests that survivors may misinterpret cognitive lapses as being due to forgetting when, in actuality, they were not able to properly encode this information at the time of initial exposure. Our objective in this study was to replicate and extend this pattern of performance to a research sample to increase the generalizability of this finding in a sample in which subjects were not clinically referred for cognitive issues. METHODS: We contrasted learning and memory performance between breast cancer survivors on endocrine therapy 2 to 6 years post-treatment with age- and education-matched healthy controls. We then stratified lower- and higher-performing breast cancer survivors to examine specific patterns of learning and memory performance. Contrasts were generated for four aggregate visual and verbal memory variables from the California Verbal Learning Test-2 (CVLT-2) and the Brown Location Test (BLT): Single-trial Learning: Trial 1 performance, Multiple-trial Learning: Trial 5 performance, Delayed Recall: Long-delay Recall performance, and Memory Errors: False-positive errors. RESULTS: As predicted, breast cancer survivors' performance as a whole was significantly lower on Single-trial Learning than the healthy control group but exhibited no significant difference in Delayed Recall. In the secondary analysis contrasting lower- and higher-performing survivors on cognitive measures, the same pattern of lower Single-trial Learning performance was exhibited in both groups, with the additional finding of significantly weaker Multiple-trial Learning performance in the lower-performing breast cancer group and intact Delayed Recall performance in both groups. CONCLUSIONS: As with our earlier finding of weaker initial encoding with intact recall in a cohort of clinically referred breast cancer survivors, our results indicate this same profile in a research sample of breast cancer survivors. Further, when the breast cancer group was stratified by lower and higher performance, both groups exhibited significantly lower performance on initial encoding, with more pronounced encoding weakness in the lower-performing group. As in our previous research, survivors did not lose successfully encoded information over longer delays, either in the lower- or higher-performing group, again arguing against memory decay in survivors. The finding of weaker initial encoding of information together with intact delayed recall in survivors points to specific treatment interventions in rehabilitation of cognitive dysfunction. IMPLICATIONS FOR CANCER SURVIVORS: The finding of weaker initial encoding of information together with intact delayed recall in survivors points to specific treatment interventions in rehabilitation of cognitive dysfunction and is discussed.

Presurgical assessment of cognitive function in pediatric brain tumor patients: feasibility and initial findings.

BACKGROUND: Establishing a presurgical baseline of neurocognitive functioning for pediatric brain tumor patients is a high priority to identify level of functioning prior to medical interventions. However, few studies have obtained adequate samples of presurgery assessments. METHODS: This study examines the feasibility of completing tests to assess pre-surgical neurocognitive functioning in 59 identified pediatric brain tumor patients. RESULTS: Eighty-five percent of patients (n = 50) were referred by the neurosurgery team before surgery and 83% of patients (n = 49) enrolled in the study. A full battery, including both performance-based and parent-report measures of neurocognitive function, was completed for 54% (n = 32) of patients. Rates of completion for either parent-report or performance-based measures were 68% (n = 40) and 69% (n = 41), respectively. While the performance-based assessment fell within the average range (M = 95.4, SD = 14.7, 95% CI, 90.7-100.0), 32% of participants had scores one or more standard deviations below the mean, or twice the expected rate. Parent-reports indicated higher level of concern than the general population (M = 55.4, SD = 11.3, 95% CI, 51.8-59.0) and found that 35% fell one or more standard deviations above the mean, or more than twice the expected rate. CONCLUSIONS: Results suggest it is feasible to conduct pre-surgical assessments with a portion of pediatric brain tumor patients upon diagnosis and these results compare favorably with prior research. However, nearly half of identified patients did not receive a full test battery. Identifying barriers to enrollment and participation in research are discussed as well as recommendations for future research.

RBANS Norms based on the Relationship of Age, Gender, Education, and WRAT-3 Reading to Performance within an Older African American Sample.

OBJECTIVE: Due to factors including differences in educational opportunity, African Americans and Caucasians frequently differ on cognitive tests creating diagnostic error risks. Such differences have been found on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), and preliminary norms based on a small sample of African Americans have been generated. In a larger sample of community-dwelling older African Americans, we explored sources of variance including age, gender, common medical conditions, years of education, and reading level to generate norms stratified on the most relevant bases. METHOD: Three hundred and fifty-five African Americans aged 55+ and living independently completed the RBANS and health, education, and psychosocial interviews. RESULTS: Hypertension and type 2 diabetes were unrelated to overall RBANS performance once age and education were accounted for. Age, education, and WRAT-3 Reading score (a proxy for scholastic attainment) were independent predictors of RBANS performance. Females performed better on List Learning, Story Memory, Fluency, Coding, List Recall, and List Recognition; males were superior on Line Orientation and Picture Naming. CONCLUSIONS: In addition to generating norms stratified by age, we provide descriptive statistics grouped by age and education, and by age and WRAT-3 Reading grade level, to provide clinicians with the opportunity to tailor their interpretation of scores based upon perceived best fit for their patient. Regression formulas are provided to address gender differences. To complement the standard index norms, we provide norms for alternative indexes representing additional an factor structure of cognitive domains.

Stress-Related Changes in Attentional Bias to Social Threat in Young Adults: Psychobiological Associations with the Early Family Environment.

This study investigated the association of chronic childhood stress exposure with acute stress-related attentional alterations that have been previously linked to vulnerability to mental and physical illness in early adulthood. Participants were randomized in a crossover design to complete both a mild laboratory social stress task and a computerized task assessing attentional bias to socially threatening words. Salivary cortisol was measured throughout the study. Exposure to acute laboratory stress altered attentional processing, and this relationship was moderated by chronic childhood stress exposure. Also, a positive association between cortisol reactivity and attentional bias was observed, with cortisol reactivity negatively related to childhood chronic stress exposure. While previous work has supported a role for early chronic stress exposure in influencing acute stress reactivity, this work provides initial insight into how both prior chronic childhood stress and current acute stress together relate to the attentional gateway and may be associated with stress adaptation and psychological vulnerability into adulthood.

Prevalence, severity and risk factors for depressive symptoms and insomnia in college undergraduates.

Although the college years represent a high-risk period for depressive symptoms and insomnia, little research has explored their prevalence, comorbidities and risk factors within this developmental period. Two studies were conducted; the first evaluated the prevalence and comorbidity of depressive symptoms and insomnia in 1338 students (ages 18-23 years) from a large Southwestern University. Mild depressive symptoms were endorsed by 19% of students and 14.5% reported moderate to severe symptoms. Forty-seven percent of students reported mild insomnia and 22.5% endorsed moderate to severe insomnia severity. A second study investigated perceived stress as a potential mediator of the relation between self-reported childhood adversity and concurrent depressive symptoms and insomnia. Undergraduates (N = 447) from a Southwestern and Southeastern University reported prior childhood adversity, current perceived stress, insomnia and depressive symptoms. Self-reported childhood adversity predicted higher levels of depressive symptoms and insomnia severity, partially mediated by perceived stress. Results support the high prevalence of depressive symptoms and insomnia among undergraduates. The risk for depressive and insomnia symptoms may be increased among students who experienced greater levels of childhood adversity.

The Association of Cytokine Levels With Cognitive Function in Children With Sickle Cell Disease and Normal MRI Studies of the Brain.

Children with sickle cell disease, including those without evidence for cerebral infarcts, are at increased risk for cognitive deficits that can contribute to difficulties in academic and social functioning. Chronic inflammatory processes are endemic to sickle cell disease and are apparent in common comorbidities including asthma. Cytokines mediating inflammatory processes can influence cognition. The authors examined the relationship between plasma levels of cytokines commonly associated with asthma and cognitive functioning using standardized neuropsychological measures in 25 children with sickle cell disease with normal magnetic resonance imaging studies of the brain. Children with sickle cell disease performed significantly below the normative mean on tests of cognitive function. Pearson correlations indicated significant negative relations between cytokines (IL-4, IL-5, IL-8, and IL-13) and standardized tests of executive function (r = -.54 to -.74). Preliminary evidence suggests an association between cytokine levels and executive function in children with sickle cell disease, indicating a potential role for inflammatory processes in cognitive outcomes in these children.

Cognitive reappraisal and secondary control coping: associations with working memory, positive and negative affect, and symptoms of anxiety/depression.

The current study examined the relations of measures of cognitive reappraisal and secondary control coping with working memory abilities, positive and negative affect, and symptoms of anxiety and depression in young adults (N=124). Results indicate significant relations between working memory abilities and reports of secondary control coping and between reports of secondary control coping and cognitive reappraisal. Associations were also found between measures of secondary control coping and cognitive reappraisal and positive and negative affect and symptoms of depression and anxiety. Further, the findings suggest that reports of cognitive reappraisal may be more strongly predictive of positive affect whereas secondary control coping may be more strongly predictive of negative affect and symptoms of depression and anxiety. Overall, the results suggest that current measures of secondary control coping and cognitive reappraisal capture related but distinct constructs and suggest that the assessment of working memory may be more strongly related to secondary control coping in predicting individual differences in distress.

Neuropsychological assessment of the orbital and ventromedial prefrontal cortex.

Assessment of the functions of the orbitofrontal cortex and ventromedial prefrontal cortex has proven to be a unique challenge for neuropsychologists. Orbitomedial damage occurs in a range of disorders including traumatic brain injury, ruptured aneurysms, surgical resection, and frontotemporal dementia. We review the effects of orbitomedial damage on a range of neuropsychological tasks, including tasks measuring object alternation and reversal learning, decision-making (gambling), facial emotion recognition, theory of mind, olfactory recognition, autobiographical memory and behavioral rating measures. At present, there is no singular gold standard measure of orbitomedial dysfunction, and assessment requires an integrative approach that reflects the heterogeneity of the region. The heterogeneous neuropsychological deficits arising from orbitomedial damage are difficult to ascribe to a unitary function or process, but appear to reflect a set of processes necessary for monitoring and adapting to changing reinforcement contingencies.

Reach of benchmark psychiatric trial results to community-based providers: a case study of CATIE.

OBJECTIVE: To evaluate the familiarity of front-line clinicians with findings from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE), the influence of didactic continuing medical education on provider knowledge about key details of CATIE, and how location-related factors affect rates of pre-event knowledge and intraevent learning about CATIE. METHOD: Data derived from the Massachusetts General Hospital Psychiatry Academy (MGH-PA) semester II live symposia provided in different cities nationally between September and December 2006 were analyzed to evaluate providers' self-assessment of their knowledge about CATIE. In addition, participants were also asked a preactivity and postactivity question to assess learning of material presented during the live event psychosis lecture. Descriptive statistics were utilized to characterize participants' self-assessment of knowledge about CATIE, while parametric and nonparametric statistical tests were used to evaluate the degree of observed learning and the effect of lecture location on the results. RESULTS: 3333 participants (mean attendance: N = 278 per event) attended 1 of the 12 MGH-PA live symposia. Of the subsample of providers who treat schizophrenia, 51% indicated that either they had never heard of CATIE or they were not familiar enough with its results to change their practice. Overall, the proportion of correct answers on the postactivity question was 65%, compared with 24% prior to the lecture (chi(2) = 48.68, df = 1, p < .001). Degree of learning did not differ among symposium locations. CONCLUSION: In this sample, the CATIE study had very limited dissemination to, and impact on, a geographically and occupationally diverse sample of mental health practitioners. Robust learning of a key methodologic detail of this trial was evidenced across symposium locations.