CHILD & ADOLESCENT RESEARCH

Title: Childhood Uniform Assessment Project (CUAP)

Investigator: Carroll W. Hughes, Ph.D.

Co-Investigators: Mark Fulton, M.D., Graham Emslie, M.D., Glen Pearson, M.D., A. John Rush, M.D.

Summary: This project is designed to develop and study a Childhood Uniform Assessment Package (CUAP) to complement the existing adult Uniform Assessment Package (UAP) developed for the Texas Department of Mental Health and Mental Retardation. It includes a computerized structured diagnostic interview (the Diagnostic Interview Schedule for Children and Adolescents - DISC) and an additional set of assessment instruments for children and adolescents modeled after those in the UAP. The study is being conducted at Terrell State Hospital (TSH) and Dallas County Mental Health and Mental Retardation (DCMHMR) with the "gold standard" diagnosis being established at the Children's Medical Center of Dallas, and The University of Texas Southwestern Medical Center. In addition to the study of the CUAP process and its reliability, research focuses on an evaluation of existing diagnostic processes in the current clinical treatment settings and their impact on service delivery systems.

Funding: National Institute of Mental Health (NIMH)

Title:  Treatment of Adolescent Depression (TADS)

Site Investigator:  Graham J. Emslie, M.D.

Site Co-Investigator:  Beth D. Kennard, Psy.D.

Summary:  According to the National Institute of Mental Health (NIMH), Major Depressive Disorder (MDD) affects about 4% of adolescents at any one time.  It is important to develop treatments to use in this population, as depression has been shown to be a risk factor for increased family stress and suicide.  The major goal of this multi-site national project is to compare fluoxetine, cognitive behavioral therapy, combination, and pill placebo in the treatment of adolescent depression.

Funding:  National Institute of Mental Health (NIMH)

Title:  Treatment of SSRI-Resistant Depression in Adolescents (TORDIA)

Site Investigator:  Graham J. Emslie, M.D.

Site Co-Investigator:  Beth D. Kennard, Psy.D.

Summary:  The first line of treatment for adolescent depression is currently the use of a selective serotonergic reuptake inhibitor (SSRI).  It has been found that up to 1/3 of cases of adolescent depression are considered to be treatment-resistant with the use of a single SSRI.  However, cognitive behavioral therapy (CBT) has also been found to be effective in the treatment of adolescent depression.  The purpose of this multi-site national study is to compare 4 treatment arms in adolescents with SSRI-resistant depression:  alternate SSRI vs. venlafaxine vs. alternate SSRI plus CBT vs. venlafaxine plus CBT.  The goal of the study is to provide clinical guidelines to be used in the challenging treatment of SSRI-resistant depression.

Funding:  National Institute of Mental Health (NIMH)

Title:  Treatment of Adolescent Suicide Attempters (TASA)

Site Investigator:  Graham J. Emslie, M.D.

Site Co-Investigator:  Beth D. Kennard, Psy.D.

Summary:  According to the National Center of Health Statistics' 2001 report, suicide is the 3rd leading cause of death in adolescents ages 15-19.  Two of the major risk factors for suicide completion are depression and history of suicide attempt.  The goal of this multi-site national project is to compare the efficacy of combined treatment with medication and cognitive behavioral therapy (CBT) plus medication alone in depressed adolescent suicide attempters.  Adolescent suicide is a significant public health problem, and there is a critical need to develop an effective treatment plan for this challenging population in order to help alleviate this public health crisis.

Funding:  National Institute of Mental Health (NIMH)

Title:  Family Functioning in Children and Adolescents with Major Depression:  Prediction of Response to Acute Treatment

Investigator:  Beth D. Kennard, Psy.D.

Summary:  Major Depressive Disorder (MDD) is often associated with increased family stress.  An important question is whether this stress (decreased family functioning) is caused by the depression or if the decreased family functioning was a contributor to the development of MDD.  The major goal of this study is to determine the contribution of family function to treatment outcomes in children and adolescents with major depression.

Funding:  Timberlawn Psychiatric Research Foundation

Title:  Family Functioning in Children and Adolescents with Eating Disorders

Investigator:  Beth D. Kennard, Psy.D.

Summary:  Children's Medical Center's inpatient psychiatry unit treats approximately 50 to 50 young people a year for eating disorders.  It has been noted that response to treatment varies significantly.  The major goal of this study is to determine the contribution of family function to treatment outcomes in children and adolescents with eating disorders.

Funding:  Timberlawn Psychiatric Research Foundation

Title:  The Relationship Between Psychosocial Functioning and Diabetes Care in Adolescents with Diabetes

Investigator:  Sunita M. Stewart, Ph.D.

Co-Investigators:  Perrin White, M.D., Graham Emslie, M.D.

Summary:  The purpose of this research is to determine the relationship that exists between children/adolescents' mood, cognitions, adherence behaviors, developmental processes (specifically development of autonomy from parents), and metabolic control.

Funding:  Timberlawn Foundation

Title:  Stress-Cortical Responsiveness, Stress and the Honeymoon Period in Newly Diagnosed Type I Diabetes

Investigator:  Sunita M. Stewart, Ph.D.

Co-Investigators:  Dana Hardin, M.D., Uma Rao, M.D.

Summary:  The purpose of this study is to investigate links between depression and diabetes that might be mediated by the hypothalamic-pituitary axis and stress.  Specifically, this research investigates the "honeymoon period" in newly diagnosed diabetic children and a) stress-cortisol responsiveness, and b) psychosocial measures of adaptation and stress.

Title:  Epidemiology of Depression and Related Disorders in Hong Kong Adolescents

Investigator:  Sunita M. Stewart, Ph.D.

Co-Investigators:  T.H. Lam, M.D., Graham Emslie, M.D., Betsy Kennard, Psy.D.

Summary:  Most of what is known about risk factors, symptom patterns and course of adolescent psychiatric disorders comes from middle class White groups.  This longitudinal research seeks to determine the cultural boundaries of the manifestation and long-term outcomes of behavioral and emotional disorders in youth.

Title: Subtypes of Children With Specific Arithmetic Disabilities and Their Response to Remedial Mathematics Intervention

Investigator: Cheryl H. Silver, Ph.D.

Co-Investigators: Jeffrey L. Black, M.D., George W. Fair, Ph.D., H. Deborah Pennett, Ph.D.

Summary: This project includes two integrated research studies. The first component involved identification and description of neuropsychological and psychosocial characteristics of homogeneous subtypes of children with arithmetic disabilities. Eighty-one children with arithmetic disability were evaluated and classified into four subtypes. Neuropsychological functions such as memory and problem-solving were measured and are being compared, as are psychosocial variables such as social skills development. Stability of subtype designation is being examined, as well. For the second component, a sample of children were selected and were given three weeks of daily mathematics instruction; controls received no intervention. Changes in mathematics skill levels, mathematics problem-solving, and self-efficacy will be examined, along with observational data from the instructional sessions.

CLINICAL HEALTH PSYCHOLOGY

Title: A Prospective Assessment and Treatment Study of TMD

Investigator: Robert J. Gatchel, Ph.D.

Co-Investigators: Peter B. Polatin, M.D., Edward Ellis III, D.D.S.

Summary: This study builds on the results of an earlier project that developed a statistical algorithm that can be used to identify acute temporomandibular (TMD) patients who are prime candidates for early intervention in order to prevent chronicity.  This continuation project involves the assessment of a large cohort of acute TMD patients in order to screen out those patients who are at "high risk" for developing chronicity.  These high-risk patients are then randomly assigned to one of two groups (30 patients/group):  an early intervention group or a non-intervention group.  The intervention procedure is modeled after that found to be most effective in the past R01 grant project--a combined biofeedback/cognitive behavioral treatment approach.  One-year follow-up evaluations will subsequently be conducted in order to assess important outcomes such as pain, disability, relapse, and health-care utilization rates.  It is hypothesized that early intervention at the acute stage will prevent the development of chronic disability.  In addition, as a replication of the previous grant project results, the non-intervention group will be compared to a demographically matched cohort (n=60) of initially assessed acute TMD patients who do not display the "high risk" profile.  It is hypothesized that the "high-risk" non-intervention group patients will demonstrate higher rates of pain and disability at one year relative to the "low risk" profile patients.

Funding: NIH

Title: Comorbidity of Physical and Mental Health Conditions

Investigator: Robert J. Gatchel, Ph.D.

Summary: The purpose of this project is to investigate the comorbidity of physical and mental health factors in TMJ disorder, the relationship between psychiatric diagnoses and chronic low back pain, and the recent work on the relationship between psychiatric diagnoses and upper extremity disorders such as carpal tunnel syndrome.

Funding: NIH

Title:  Preventing Co-morbid Mental & Physical Health Disability

Investigator:  Robert J. Gatchel, Ph.D.

Co-Investigators:  Peter Polatin, M.D., Glenn Pransky, M.D., William Shaw, Ph.D.

Summary:  The major aim of this study is to evaluate the therapeutic- and cost-effectiveness of a three-component biopsychosocial model of early intervention in order to maximize the prevention of chronicity in high-risk acute low back pain patients.  This translational biopsychosocial research is being conducted in partnership with the largest workers' compensation company in the U.S. (Liberty Mutual).

Funding:  NIH

Title:  A Randomized Trial of Musculoskeletal Pain Treatment in a Military Population

Investigator:  Robert J. Gatchel, Ph.D.

Co-Investigators:  Lt. Col. Alan L. Peterson, Ph.D., Cpt. Christine Hunter, Ph.D., Cpt. Christopher Hunter, Ph.D., Maj. Mark Oordt, Ph.D.

Summary:  The Department of Defense pays over $1.6 billion annually to disabled service members, and musculoskeletal conditions account for 40-50% of this amount.  The major goal of this study is to test the hypothesis that an interdisciplinary chronic pain rehabilitation program (ICRP) will demonstrate efficacy in returning chronic disability patients to work that is comparable to the results demonstrated in studies conducted with civilian populations

Funding:  Department of Defense

MENTAL HEALTH SERVICES RESEARCH

Title: Relative Cost-Effectiveness of Peer and Professional Counselors in the Production of Transitional Case Management 

Investigator: T. Michael Kashner, Ph.D., J.D.

Co-Investigators: Mary Turner, Ph.D., Maurice Korman, Ph.D.

Summary: This study evaluates the Dallas County MHMR Transitional Aides (TA) program. This program targets patients being discharged from Terrell State Hospital who will begin receiving psychiatric care at DCMHMR's Outpatient Clinics. The TA program utilizes former patients who serve as peers. This study follows the costs and health outcome of patients discharged between October 1, 1994, and January 1, 1995. At discharge, the patient is assigned: 1) to the TA program, 2) to a case manager; or 3) to neither. Outcomes include patient use of positive services such as routine MHMR clinic visits and use of negative services such as crisis lines, inpatient psychiatric care, and psychiatric emergency room care.

Funding: Dallas County MHMR, Mental Health Connections

Title: Evaluations of the Diagnostic Quality Assurance Program

Investigator: T. Michael Kashner, Ph.D., J.D.

Co-Investigators: Kenneth Z. Altshuler, M.D., Monica R. Basco, Ph.D., Phyllis Gibson, A. John Rush, M.D., Larry Tripp, M.D.

Summary: This randomized, controlled trial is designed to evaluate the cost and health outcomes of the proposed Diagnostic Quality Assurance Program (DQAP) for the Dallas County MHMR. When fully implemented, DQAP will employ psychiatric nurses to administer Structured Clinical Interviews (SCIDs) to new patients who receive care at MHMR outpatient mental health clinics. Patients whose SCID diagnosis is inconsistent with the clinical diagnosis are considered to be at risk of having an incorrect clinical diagnosis in need of updating. DQAP will be implemented at two clinics, with a third serving as a control. During one year, an estimated 1,800 new patients will begin care at either one of the two participating clinics. They will be randomized to either a SCID (n=900) or no-SCID (n=900). Clinical outcomes are measured directly from Global Assessment of Functioning (GAF) scores determined by the attending clinician and indirectly from patient's use of "negative" services (psychiatric emergency rooms, crisis lines, psychiatric inpatient care) and "positive" services (routine clinic visits). Costs are divided into those for the nurses who administer SCIDs and those the patient uses as a consequence of updating their diagnosis.

Funding: Dallas County MHMR, Mental Health Connections

Title: Cost-Effectiveness of Assertive Community Treatment in Caring for the Severely Mentally Ill

Investigator: T. Michael Kashner, Ph.D., J.D.

Co-Investigators: Monica R. Basco, Ph.D., Phyllis Gibson, Gretchen L. Megowen, M.D., A. John Rush, M.D., Larry Tripp, M.D.

Summary: This study is designed to evaluate the costs and outcome of a 6- to 9- month Assertive Clinical Treatment (ACT) program that provides coordinated clinical teams and aggressive case management to severely mentally ill patients in community settings. Of 100 patients who qualify for ACT, 50 will be randomized to receive ACT immediately and 50 will be randomized to usual care. Patients randomized to usual care will be ineligible to receive ACT for 9 months. Outcomes are measured directly by assessing patient GAF scores at one-month intervals during the study and measured indirectly by examining patient use of crisis services, psychiatric emergency room and acute inpatient care facilities. Costs are assessed based on reimbursement rates and cost of provider time. Cross section/time series models will be used to estimate the impact of being in the ACT program as well as the volume of intensive case management services on patient outcome and costs.

Funding: Dallas County MHMR, Mental Health Connections

NEUROPSYCHOLOGY RESEARCH

Title: Cerebral Functioning in Persons at Increased Risk for Alzheimer's Disease 

Investigator: C. Munro Cullum, Ph.D.

Summary: This project examines cognitive functions with and without a family history of Alzheimer's disease (AD) in order to examine whether those at increased genetic risk for the illness demonstrate different patterns of memory and cognitive performance than similar individuals without a family history of AD. Special interest is being paid to episodic memory function, one of the abilities often affected early in the course of AD.

Funding: Alzheimer's Association

Title: Functional MRI in Aging and Dementia

Investigator: C. Munro Cullum, Ph.D.

Co-Investigators:  Greg Allen, Ph.D., Roderick McGill, Ph.D., Craig Rubin, M.D., Anne Lipton, M.D.

Summary: This is a pilot project to examine the feasibility of using Functional MRI (fMRI) in healthy older adults and in patients in the early stages of Alzheimer's disease. Several studies have found regional cerebral activation during motor and cognitive challenge test compared with the brain at rest. Whether fMRI techniques are useful in the early detection of abnormal brain function in AD remains a question, in addition to the question of what constitutes normal age-related changes in blood flow.

Title:  Psychoeducational Intervention in Patients with Cerebral Aneurysm:  Impact Upon Adjustment and Recovery

Investigator:  C. Munro Cullum, Ph.D.

Co-Investigators:  Kathy Saine, Ph.D., Ann Matt Maddrey, Ph.D.

Summary:  A psychoeducational intervention program is proposed that will provide patients undergoing surgical treatment for cerebral aneurysm with support and detailed information about the cognitive, emotional, and psychological sequelae that may be experienced during surgery.  It is hypothesized that early psychoeducational intervention provided by a neuropsychologist to a randomly selected sample of consecutive aneurysm patients will result in fewer subsequent cognitive and emotional complaints and perceived problems during recovery, and may signiticantly impact subsequent health care costs.

Funding:  Mobility Center

Title:   Functional Magnetic Resonance Imaging of Cerebellar Learning in Autism

Investigator:  Greg Allen, Ph.D.

Summary:  This study will utilize functional MRI (FMRI) to investigate cerebellar learning mechanisms in autism.  Individuals with autism and normal controls will undergo FMRI as they perform the serial reaction time task (SRTT), a standard tool for studying the neural basis of visual-motor learning. In normal subjects performing the SRTT, exposure to a repeating sequence of visual stimuli is accompanied by learning as indexed by decreased reaction time (RT) to these stimuli, even when subjects are unaware of the sequence.  Such learning is paralleled by changes in cerebellar activation.  Individuals with damage to the cerebellum do not show learning-related changes in RT, and individuals with autism also show impaired learning on this task. The proposed study will examine the relationship between such impairment and cerebellar dysfunction, and more importantly, it will investigate a potential neurofunctional link between cerebellar pathology and the symptoms of autism.

Funding:  Cure Autism Now Foundation

Title:  Classification of Memory Subtypes of Mild Cognitive Impairment

Investigator:  Laura H. Lacritz, Ph.D.

Summary:  This study examines early detection of Mild Cognitive Impairment (MCI), typically thought of as a precursor stage of Alzheimer's disease, and the presence of specific memory subtypes within the disease.  Preliminary research has demonstrated evidence of asymmetric patterns of cognitive functioning in individuals evaluated for memory complaints, some of whom meet the current criteria for MCI.  This study aims to:  1) validate the existence of memory subtypes of MCI:  Verbal, Nonverbal and Mixed Memory; 2) delineate demographic characteristics of each subtype; 3) examine imaging characteristics, biomarkers, and functional abilities of each subtype; and 4) establish reliable diagnostic criteria for memory subtypes of MCI.

Funding:  Alzheimer's Disease Center/NIH (National Institute of Aging)

Investigator: Cheryl H. Silver, Ph.D.

Co-Investigators: H. Deborah Pennett, Ph.D., Carrie E. Molho, Laura Goulden, Catherine Bass

Summary: This project involves the development and use of measures appropriate for children that can identify impairment in executive functions such as planning, problem-solving, and adjusting one's behaviors to feedback. A new scoring system for a well-validated test of problem-solving was developed; reliability for the scoring system has been established and preliminary normative data are being collected locally. A new rating scale for adaptive problem-solving in daily life is under development; its utility with children who have a wide variety of developmental disabilities and acquired neuropsychological impairments will be evaluated.

NEURORECEPTOR/NEUROENDOCRINE RESEARCH

Title: Cholinergic Abnormalities in Schizophrenia

Investigator: Dwight C. German, Ph.D.

Summary: Neurons that contain acetylcholine have been implicated in the pathophysiology of schizophrenia. Using immunohistochemical staining and computer imaging procedures, we have found marked decreases in the number of cholinergic neurons in the striatum of postmortem schizophrenic brains compared to nonschizophrenic controls. These neurons may serve to link portions of the brain that are involved with cognition and emotion. Because the schizophrenic brains are from patients treated chronically with neuroleptic drugs, however, we are also examining the same cholinergic neuronal population in rats treated chronically with neuroleptics.

Funding: Mathers Charitable Trust; Stanley Foundation

Title: Biological Predictors of First Onset in Those At Risk for Mood Disorders

Investigator: A. John Rush, M.D.

Co-Investigators: Roseanne Armitage, Ph.D., Mark A. Fulton, M.D.

Summary: Two measures, plasma g-aminobyteric acid (GABA) and selected aspects of the sleep electroencephalogram (EEG) appear to differentiate symptomatic and remitted depressed patients from controls. These abnormalities may also be present in depressed children and adolescents. This investigation is designed to evaluate whether these abnormalities are found in those at risk for the illness, based on the family history of probands who have not yet passed through the age of risk by (1) conducting laboratory studies of these subjects and (2) following up (every six months) those with and without the abnormalities to see if their presence predicts the onset of the illness. Other pilot studies (e.g., those involving subjects with mood disorders due to general medical conditions as well as pharmacological challenges) are also being conducted to determine the biological basis for these abnormalities.

Funding: NARSAD, other private foundations

PSYCHOSOCIAL AND COGNITIVE THERAPY RESEARCH

Title: Is Cognitive Therapy Prophylactic for Recurrent Depression?

Investigator: Robin B. Jarrett, Ph.D.

Co-Investigators: Delores Kraft, Ph.D.

Summary: The purpose of this controlled, randomized clinical trial is to compare the differential efficacy of an acute phase of cognitive therapy (CT) followed by an eight-month continuation phase or an acute phase of cognitive therapy without a continuation phase in reducing the probability of relapse/recurrence during the first eight months following acute treatment in outpatients with DSM-IV recurrent major depressive disorder (MDD). This study is important because MDD is prevalent and has high economic and human costs and recurs in approximately 50-85 percent of cases. Pilot data collected from the Psychosocial Research and Depression Clinic suggested that with continuation CT, the probability of relapse/recurrence could be decreased during the eight months immediately following an acute phase of CT. If within the first eight months following the acute CT phase the relapse/recurrence rate in this study is 30 percent or less, we will judge such prophylaxis to be clinically important and conclude that CT for recurrent depression may offer an alternative to continuation phase therapy using antidepressant medication. This study is the first controlled, randomized evaluation of the probability of relapse/recurrence following an acute phase of CT. It is also the first CT study aimed specifically at outpatients suffering from recurrent major depressive disorder. In contrast to available studies, relapse/recurrence is defined as meeting DSM-IV criteria for major depressive disorder.

Funding: NIMH

Title: Psychosocial Research and Depression Clinic

Investigator: Robin B. Jarrett, Ph.D.

Co-Investigators: Dolores Kraft, Ph.D.

Summary: The purpose of the Psychosocial Research and Depression Clinic is to study short-term psychosocial interventions which show promise in the treatment of mood, anxiety, and personality disorders. A variety of psychosocial parameters are assessed which may influence treatment outcome, course of illness, or might otherwise elucidate the connection between psychosocial and biological factors involved in the course of mood disorders. Collaboration with investigators interested in biological psychiatry and treatment is encouraged. The research clinic exists to provide high-quality controlled treatment to patients who are eligible for systematic research protocols and to train and maintain a cadre of skilled therapists. A small number of patients ineligible for research but needing psychotherapy are accepted as teaching and training cases when possible. The Psychosocial Research and Depression Clinic accepts applications from psychotherapists who wish to receive training in cognitive therapy for the purpose of treating subjects in ongoing clinical trials or studies.

Title:  Temporal Stability of Dimensional Personality Trait Expression

Investigator:  Cindy Claassen, Ph.D.

Co-Investigator (Mentor):  A. John Rush, M.D.

Summary:  Overall Aim:  The general aim of this study is to correlate key environmental precipitants with impulsive aggressive trait expression in self-harm and traumatic injury victims.  Methods:  Approximately 200 self-harm and traumatic injury patients diagnosed with Borderline Personality Disorder will be recruited for the study in the Emergency Room of Parkland Hospital, a large teaching hospital in Dallas, Texas over the 16-month recruitment period.  Study patients will be given a battery of tests to determine Axis I and II diagnoses, level of depressive symptomatology, history of abuse and psychiatric treatment, and qualities of impulsive aggressive trait expression.  Also measured will be recent life stressors, along with sensation-seeking correlates and qualities of the current self-harm attempt in self-injurious patients.  Outcome six months post-injury will be correlated with predictor variables using multiple regression and structural modeling techniques to characterize the relationship between trait expression and environmental "triggers."

Funding:  Borderline Personality Disorder Research Foundation