Computational Psychiatry: towards a mathematically informed understanding of mental illness

Computational Psychiatry aims to describe the relationship between the brain's neurobiology, its environment and mental symptoms in computational terms. In so doing, it may improve psychiatric classification and the diagnosis and treatment of mental illness. It can unite many levels of description in a mechanistic and rigorous fashion, while avoiding biological reductionism and artificial categorisation. We describe how computational models of cognition can infer the current state of the environment and weigh up future actions, and how these models provide new perspectives on two example disorders, depression and schizophrenia. Reinforcement learning describes how the brain can choose and value courses of actions according to their long-term future value. Some depressive symptoms may result from aberrant valuations, which could arise from prior beliefs about the loss of agency ('helplessness'), or from an inability to inhibit the mental exploration of aversive events. Predictive coding explains how the brain might perform Bayesian inference about the state of its environment by combining sensory data with prior beliefs, each weighted according to their certainty (or precision). Several cortical abnormalities in schizophrenia might reduce precision at higher levels of the inferential hierarchy, biasing inference towards sensory data and away from prior beliefs. We discuss whether striatal hyperdopaminergia might have an adaptive function in this context, and also how reinforcement learning and incentive salience models may shed light on the disorder. Finally, we review some of Computational Psychiatry's applications to neurological disorders, such as Parkinson's disease, and some pitfalls to avoid when applying its methods

Evolution of planetary systems with time-dependent stellar mass-loss

Observations indicate that intermediate mass stars, binary stars, and stellar remnants often host planets; a full explanation of these systems requires an understanding of how planetary orbits evolve as their central stars lose mass. Motivated by these dynamical systems, this paper generalizes previous studies of orbital evolution in planetary systems with stellar mass loss, with a focus on two issues: [1] Whereas most previous treatments consider constant mass loss rates, we consider single planet systems where the stellar mass loss rate is time dependent; the mass loss rate can be increasing or decreasing, but the stellar mass is always monotonically decreasing. We show that the qualitative behavior found previously for constant mass loss rates often occurs for this generalized case, and we find general conditions required for the planets to become unbound. However, for some mass loss functions, where the mass loss time scale increases faster than the orbital period, planets become unbound only in the asymptotic limit where the stellar mass vanishes. [2] We consider the chaotic evolution for two planet systems with stellar mass loss. Here we focus on a simple model consisting of analogs of Jupiter, Saturn, and the Sun. By monitoring the divergence of initially similar trajectories through time, we calculate the Lyapunov exponents of the system. This analog solar system is chaotic in the absence of mass loss with Lyapunov time τ0 ≈ 5 Myr; we find that the Lyapunov time decreases with increasing stellar mass loss rate, with a nearly linear relationship between the two time scales. Taken together, results [1] and [2] help provide an explanation for a wide range of dynamical evolution that occurs in solar systems with stellar mass loss. Subject headings: planets and satellites: dynamical evolution and stability — planet-star interactions — stars: evolution — stars: mass loss — white dwarfs – 2 – 1

Mass Drug Administration and beyond: how can we strengthen health systems to deliver complex interventions to eliminate neglected tropical diseases?

Achieving the 2020 goals for Neglected Tropical Diseases (NTDs) requires scale-up of Mass Drug Administration (MDA) which will require long-term commitment of national and global financing partners, strengthening national capacity and, at the community level, systems to monitor and evaluate activities and impact. For some settings and diseases, MDA is not appropriate and alternative interventions are required. Operational research is necessary to identify how existing MDA networks can deliver this more complex range of interventions equitably. The final stages of the different global programmes to eliminate NTDs require eliminating foci of transmission which are likely to persist in complex and remote rural settings. Operational research is required to identify how current tools and practices might be adapted to locate and eliminate these hard-to-reach foci. Chronic disabilities caused by NTDs will persist after transmission of pathogens ceases. Development and delivery of sustainable services to reduce the NTD-related disability is an urgent public health priority. LSTM and its partners are world leaders in developing and delivering interventions to control vector-borne NTDs and malaria, particularly in hard-to-reach settings in Africa. Our experience, partnerships and research capacity allows us to serve as a hub for developing, supporting, monitoring and evaluating global programmes to eliminate NTDs

Chlorpromazine for schizophrenia: a Cochrane systematic review of 50 years of randomised controlled trials

BACKGROUND: Chlorpromazine (CPZ) remains one of the most common drugs used for people with schizophrenia worldwide, and a benchmark against which other treatments can be evaluated. Quantitative reviews are rare; this one evaluates the effects of chlorpromazine in the treatment of schizophrenia in comparison with placebo. METHODS: We sought all relevant randomised controlled trials (RCT) comparing chlorpromazine to placebo by electronic and reference searching, and by contacting trial authors and the pharmaceutical industry. Data were extracted from selected trials and, where possible, synthesised and random effects relative risk (RR), the number needed to treat (NNT) and their 95% confidence intervals (CI) calculated. RESULTS: Fifty RCTs from 1955–2000 were included with 5276 people randomised to CPZ or placebo. They constitute 2008 person-years spent in trials. Meta-analysis of these trials showed that chlorpromazine promotes a global improvement (n = 1121, 13 RCTs, RR 0.76 CI 0.7 to 0.9, NNT 7 CI 5 to 10), although a considerable placebo response is also seen. People allocated to chlorpromazine tended not to leave trials early in both the short (n = 945, 16 RCTs, RR 0.74 CI 0.5 to 1.1) and medium term (n = 1861, 25 RCTs, RR 0.79 CI 0.6 to 1.1). There were, however, many adverse effects. Chlorpromazine is sedating (n = 1242, 18 RCTs, RR 2.3 CI 1.7 to 3.1, NNH 6 CI 5 to 8), increases a person's chances of experiencing acute movement disorders, Parkinsonism and causes low blood pressure with dizziness and dry mouth. CONCLUSION: It is understandable why the World Health Organization (WHO) have endorsed and included chlorpromazine in their list of essential drugs for use in schizophrenia. Low- and middle-income countries may have more complete evidence upon which to base their practice compared with richer nations using recent innovations

Derived neutrophil lymphocyte ratio is predictive of survival from intermittent therapy in advanced colorectal cancer: a post hoc analysis of the MRC COIN study

BACKGROUND: The phase III COntinuous or INtermittent (COIN) trial failed to show non-inferiority of intermittent compared with continuous chemotherapy for advanced colorectal cancer in overall survival (OS). The present analysis evaluated whether the derived neutrophil to lymphocyte ratio (dNLR) could predict the effect of intermittent vs continuous chemotherapy on OS in patients with advanced colorectal cancer. METHODS: A post hoc exploratory analysis of COIN arms A and C was performed. Landmark analysis was conducted on all patients with available WBC and neutrophils data. The dNLR was calculated using a formula which has previously demonstrated predictive power in cancer patients: dNLR=ANC/(WBC−ANC). A high dNLR was defined using a cut-off value of ⩾2.22. Derived neutrophil to lymphocyte ratio was then correlated with clinical outcomes. Survival curves were generated based on dNLR using the Kaplan–Meier method. Comparison between groups was performed using Cox regression. RESULTS: A total of 1630 patients were assigned to the continuous (N=815) or intermittent (N=815) arms. There was a strong association between dNLR level and OS. The median survival times in the ITT population were 18.6 months and 12.5 months for patients with low and high dNLR, respectively (HR=1.70; 95% CI=1.52–1.90; P<0.001). The estimate of the hazard ratio did not alter substantially (HR=1.54) after adjusting for treatment, tumour status, number of metastatic sites, alkaline phosphate and platelet count. CONCLUSIONS: Derived neutrophil to lymphocyte ratio is strongly prognostic for survival in the COIN intermittent vs continuous treatment arms. Derived neutrophil to lymphocyte ratio does not predict for detrimental survival in patients treated with intermittent therapy

Impact of Radiotherapy, Chemotherapy and Surgery in Multimodal Treatment of Locally Advanced Esophageal Cancer

Objectives: It was the aim of this study to assess our institutional experience with definitive chemoradiation (CRT) versus induction chemotherapy followed by CRT with or without surgery (C-CRT/S) in esophageal cancer. Methods: We retrospectively analyzed 129 institutional patients with locally advanced esophageal cancer who had been treated by either CRT in analogy to the RTOG 8501 trial (n = 78) or C-CRT/S (n = 51). Results: The median, 2-and 5-year overall survival (OS) of the entire collective was 17.6 months, 42 and 24%, respectively, without a significant difference between the CRT and C-CRT/S groups. In C-CRT/S patients, surgery statistically improved the locoregional control (LRC) rates (2-year LRC 73.6 vs. 21.2%; p = 0.003); however, this was translated only into a trend towards improved OS (p = 0.084). The impact of escalated radiation doses (>= 60.0 vs. <60.0 Gy) on LRC was detectable only in T1-3 N0-1 M0 patients of the CRT group (2-year LRC 77.8 vs. 42.3%; p = 0.036). Conclusion: Definitive CRT and a trimodality approach including surgery (C-CRT/S) had a comparable outcome in this unselected patient collective. Surgery and higher radiation doses improve LRC rates in subgroups of patients, respectively, but without effect on OS. Copyright (C) 2012 S. Karger AG, Base

Predictors of failed attendances in a multi-specialty outpatient centre using electronic databases.

BACKGROUND: Failure to keep outpatient medical appointments results in inefficiencies and costs. The objective of this study is to show the factors in an existing electronic database that affect failed appointments and to develop a predictive probability model to increase the effectiveness of interventions. METHODS: A retrospective study was conducted on outpatient clinic attendances at Tan Tock Seng Hospital, Singapore from 2000 to 2004. 22864 patients were randomly sampled for analysis. The outcome measure was failed outpatient appointments according to each patient's latest appointment. RESULTS: Failures comprised of 21% of all appointments and 39% when using the patients' latest appointment. Using odds ratios from the mutliple logistic regression analysis, age group (0.75 to 0.84 for groups above 40 years compared to below 20 years), race (1.48 for Malays, 1.61 for Indians compared to Chinese), days from scheduling to appointment (2.38 for more than 21 days compared to less than 7 days), previous failed appointments (1.79 for more than 60% failures and 4.38 for no previous appointments, compared with less than 20% failures), provision of cell phone number (0.10 for providing numbers compared to otherwise) and distance from hospital (1.14 for more than 14 km compared to less than 6 km) were significantly associated with failed appointments. The predicted probability model's diagnostic accuracy to predict failures is more than 80%. CONCLUSION: A few key variables have shown to adequately account for and predict failed appointments using existing electronic databases. These can be used to develop integrative technological solutions in the outpatient clinic

Whole-tree chambers for elevated atmospheric CO<inf>2</inf> experimentation and tree scale flux measurements in south-eastern Australia: The Hawkesbury Forest Experiment

Resolving ecophysiological processes in elevated atmospheric CO2 (Ca) at scales larger than single leaves poses significant challenges. Here, we describe a field-based experimental system designed to grow trees up to 9m tall in elevated Ca with the capacity to control air temperature and simultaneously measure whole-tree gas exchange. In western Sydney, Australia, we established the Hawkesbury Forest Experiment (HFE) where we built whole-tree chambers (WTC) to measure whole-tree CO2 and water fluxes of an evergreen broadleaf tree, Eucalyptus saligna. A single E. saligna tree was grown from seedling to small tree within each of 12 WTCs; six WTCs were maintained at ambient Ca and six WTCs were maintained at elevated Ca, targeted at ambient Ca +240μmolmol-1. All 12 WTCs were controlled to track ambient outside air temperature (Tair) and air water vapour deficit (Dair). During the experimental period, Tair, Dair and Ca in the WTCs were within 0.5°C, 0.3kPa, and 15μmolmol-1 of the set-points for 90% of the time, respectively. Diurnal responses of whole-tree CO2 and water vapour fluxes are analysed, demonstrating the ability of the tree chamber system to measure rapid environmental responses of these fluxes of entire trees. The light response of CO2 uptake for entire trees showed a clear diurnal hysteresis, attributed to stomatal closure at high Dair. Tree scale CO2 fluxes confirm the hypothesised deleterious effect of chilling night-time temperatures on whole-tree carbon gain in this subtropical Eucalyptus. The whole-tree chamber flux data add an invaluable scale to measurements in both ambient and elevated Ca and allow us to elucidate the mechanisms driving tree productivity responses to elevated Ca in interaction with water availability and temperature. © 2010 Elsevier B.V

Country differences in the diagnosis and management of coronary heart disease : a comparison between the US, the UK and Germany

Background The way patients with coronary heart disease (CHD) are treated is partly determined by non-medical factors. There is a solid body of evidence that patient and physician characteristics influence doctors' management decisions. Relatively little is known about the role of structural issues in the decision making process. This study focuses on the question whether doctors' diagnostic and therapeutic decisions are influenced by the health care system in which they take place. This non-medical determinant of medical decision-making was investigated in an international research project in the US, the UK and Germany. Methods Videotaped patients within an experimental study design were used. Experienced actors played the role of patients with symptoms of CHD. Several alternative versions were taped featuring the same script with patients of different sex, age and social status. The videotapes were shown to 384 randomly selected primary care physicians in the three countries under study. The sample was stratified on gender and duration of professional experience. Physicians were asked how they would diagnose and manage the patient after watching the video vignette using a questionnaire with standardised and open-ended questions. Results Results show only small differences in decision making between British and American physicians in essential aspects of care. About 90% of the UK and US doctors identified CHD as one of the possible diagnoses. Further similarities were found in test ordering and lifestyle advice. Some differences between the US and UK were found in the certainty of the diagnoses, prescribed medications and referral behaviour. There are numerous significant differences between Germany and the other two countries. German physicians would ask fewer questions, they would order fewer tests, prescribe fewer medications and give less lifestyle advice. Conclusion Although all physicians in the three countries under study were presented exactly the same patient, some disparities in the diagnostic and patient management decisions were evident. Since other possible influences on doctors treatment decisions are controlled within the experimental design, characteristics of the health care system seem to be a crucial factor within the decision making process

Interactive effects of elevated CO <inf>2</inf> and drought on nocturnal water fluxes in Eucalyptus saligna

Nocturnal water flux has been observed in trees under a variety of environmental conditions and can be a significant contributor to diel canopy water flux. Elevated atmospheric CO 2 (elevated [CO 2]) can have an important effect on day-time plant water fluxes, but it is not known whether it also affects nocturnal water fluxes. We examined the effects of elevated [CO 2] on nocturnal water flux of field-grown Eucalyptus saligna trees using sap flux through the tree stem expressed on a sapwood area (J s) and leaf area (E t) basis. After 19 months growth under well-watered conditions, drought was imposed by withholding water for 5 months in the summer, ending with a rain event that restored soil moisture. Reductions in J s and E t were observed during the severe drought period in the dry treatment under elevated [CO 2], but not during moderate- and post-drought periods. Elevated [CO 2] affected night-time sap flux density which included the stem recharge period, called 'total night flux' (19:00 to 05:00, J s,r), but not during the post-recharge period, which primarily consisted of canopy transpiration (23:00 to 05:00, J s,c). Elevated [CO 2] wet (EW) trees exhibited higher J s,r than ambient [CO 2] wet trees (AW) indicating greater water flux in elevated [CO 2] under well-watered conditions. However, under drought conditions, elevated [CO 2] dry (ED) trees exhibited significantly lower J s,r than ambient [CO 2] dry trees (AD), indicating less water flux during stem recharge under elevated [CO 2]. J s,c did not differ between ambient and elevated [CO 2]. Vapour pressure deficit (D) was clearly the major influence on night-time sap flux. D was positively correlated with J s,r and had its greatest impact on J s,r at high D in ambient [CO 2]. Our results suggest that elevated [CO 2] may reduce night-time water flux in E. saligna when soil water content is low and D is high. While elevated [CO 2] affected J s,r, it did not affect day-time water flux in wet soil, suggesting that the responses of J s,r to environmental factors cannot be directly inferred from day-time patterns. Changes in J s,r are likely to influence pre-dawn leaf water potential, and plant responses to water stress. Nocturnal fluxes are clearly important for predicting effects of climate change on forest physiology and hydrology. © 2011 The Author. Published by Oxford University Press. A ll rights reserved