Dr. Randall White at the 9th Annual Pacific Psychopharmacology Conference

Dr. Randall White is pleased to be attending the 9th Annual Pacific Psychopharmacology Conference this September where he will be Co-chairing the pre-conference and moderating many of the conference sessions. Join us to learn what’s new in evidence-based research on the pharmacotherapy of psychiatric illness.

This year’s conference theme is: Balancing Risks and Benefits to Improved Adherence

The pre-conference workshop title is: Strategies for Managing Mood and Anxiety Disorders in Primary Care at the workshop. The workshop will also cover the following topics in the format of brief presentations with cases:

  • Incorporating Measurement-Based Care for Mood Disorders into Clinical Practice
  • The BC Practice Support Program Adult Mental Health Module: Implications for Primary Care
  • Use of Antidepressants in Ambulatory Settings

Key speakers for the conference:

Martha Sajatovic, MD
Treatment Adherence in Bipolar Disorder
Dr. Martha Sajotovic, is a professor of Psychiatry and Neurology at Case Western Reserve University. She is also a director of the Geropsychiatry Program, and Neurological and Behavioral Outcomes Center, University Hospitals Case Medical Center, and a Willard Brown Chair in Neurological Outcomes Research, Cleveland. Her research focus is on treatment adherence in Bipolar Disorder and Improving Outcomes for People with Schizophrenia.

Robert Zipursky, MD, FRCPC
Improving Outcomes for People with Schizophrenia
Dr. Zipursky is a professor, Department of Psychiatry & Behavioural Neurosciences. ‘s research interests have been in investigating the biology of schizophrenia and its treatment using brain imaging techniques (CT, MRI, PET), the treatment of first episode psychosis, prevention of schizophrenia, and clinical outcomes from schizophrenia. He has served on the editorial boards of Schizophrenia Research and Schizophrenia Bulletin. He is a recipient of the John Cleghorn Memorial Award for Excellence and Leadership in Clinical Research from the Canadian Psychiatric Association and the Michael Smith Award from the Schizophrenia Society of Canada.If you are planning to attend, please introduce yourself to Randall! And if you’re coming from out of town, Be sure to ask for the “Annual Pacific Psychopharmacology Conference 2015” rate or quote booking ID #15906 at time of booking.

Pre-conference Workshop Information
September 17, 2015
Time: 1-4pm, lunch provided prior to course at 12:30pm
Cost: $119 for delegates, $69 for residents, apply a $25 discount if you register for the Sept. 18 conference as well

This workshop will be great for nurse practitioners, pharmacy/therapeutics, psychiatrists, registered nurses, residents and students.

Conference Details:
September 18, 2015
Executive Plaza Hotel and Conference Centre

Social Media:
Follow Dr. Randall White @BCPsychosis on Twitter, use #CPDpppc to follow the conference.

Transcranial direct current stimulation (tDCS) for treatment-resistant psychosis

Neurostimulation techniques are a growing aspect of psychiatric treatment especially as advances in pharmacotherapy have slowed down. Although electroconvulsive therapy (ECT) remains the best studied and perhaps most efficacious form of neurostimulation for treatment-resistant psychosis and mood disorders, it is invasive, requires considerable resources, and remains stigmatized. tDCS by contrast is noninvasive, requires few resources, and has never been portrayed as a form of punishment in novels and films. Although its efficacy for psychosis is yet to be fully established, evidence is accumulating. Because tDCS is relatively easy to administer, controlled experiments with active and sham treatment groups are feasible.

tDCS involves the passage of an electrical current of 1-2 milliamperes across the cerebral cortex by means of 2 electrodes placed on the scalp. To diminish auditory hallucinations, electrodes are placed on the left fronto-temporal region; for negative symptoms, bifrontal placement has been used. The treatment is typically given for 20 minutes twice a day for at least 5 days. Adverse effects are minimal but may include tingling or itching at the site of electrode placement and short-lived somnolence.

According to a review by Mondino, Fecteau and colleagues, 32 studies have examined the effects of tDCS in schizophrenia. Most studies involved patients who were also receiving medication, and several case reports have described safe combination with clozapine. For auditory hallucinations, 14 studies exist including 2 randomized controlled trials (RCTs) which included a total of 54 patients. One RCT found a 30% reduction in treatment-resistant auditory hallucinations after 10 sessions, significantly greater than in the sham-treatment group. The second RCT, however, did not find a significant reduction in auditory hallucinations. The treatment parameters differed between the studies, which confounds interpretation; for instance, in the positive trial, subjects received tDCS twice daily whereas in the negative trial, tDCS was once daily.

In the review, the authors also describe investigations of tDCS on such parameters as functional MRI, auditory and motor evoked potentials, and cognitive measures including executive function. Questions yet to answered include the appropriate duration of each tDCS session, 20 minutes being the most usual; the total duration of treatment, i.e. days or weeks; and the placement of electrodes. The duration of beneficial effect is uncertain, although data to date suggest it may endure for several months, and the role of maintenance treatment requires considerable investigation.


Mondino M, Brunelin J, Palmc U, Brunonid AR, Pouleta E and Fecteau S. Transcranial direct current stimulation for the treatment of refractory symptoms of schizophrenia: current evidence and future directions. Current Pharmaceutical Design. 2015;21:3373-3383. Abstract

Refugees in Canada have a high incidence of psychosis

A recent article which I reviewed found evidence for an increasing incidence of schizophrenia in Canada. The researcher speculated that Canada’s high rate of immigration may contribute to this finding. Studies from other industrialized countries have found that immigrants, both in the first and second generation, have an elevated risk of developing schizophrenia, but evidence of this in Canada is lacking. A group from the Centre for Addictions and Mental Health in Toronto estimated the incidence of schizophrenia and schizoaffective disorder in Ontario, the most populous and immigrant-rich province of Canada, by examining hospital and billing records with the records maintained by Canadian immigration authorities.

The identified cohort was all Ontario residents who were age 14 to 40 years at the beginning of the 10-year period from 1999-2008. Because of the universal health-care system, all people who come to medical attention have their diagnosis recorded in a provincial data set. All those listed as an immigrants by the federal ministry of citizenship were classified as such whereas all those not listed were classified as non-immigrants. The investigators also noted which immigrants were admitted under refugee status, an indication of a more vulnerable and likely trauma-exposed group.

The rate of new-onset psychosis in the general population was 55.6 (95% CI 54.9–56.4) per 100 000 person-years and 51.7 (95% CI 49.2–54.4) per 100 000 person-years in first-generation immigrants; these rates are not significantly different. Among the immigrants classified as refugees, the rate was higher: 72.8 (95% CI 67.1– 78.9) per 100 000 person-years, but this is not significantly different from the other rates. Closer examination found that immigrants of various origins had differing rates; those from the Caribbean and Bermuda had significantly higher risk whereas those from northern and southern Europe and east Asia had significantly lower risk than the general population. Among refugees, those from east Africa and south Asia had significantly greater risk of psychosis than the general population.

The shortcomings of this kind of study are considerable, mainly the retrospective design and the reliance on administrative-level diagnostic data. Furthermore, the general population included second-generation immigrants who could not be identified by the study methods but who also probably have a higher risk of psychosis. Moreover, the researchers mention that refugees often have other mental illnesses such as posttraumatic stress disorder which may be misdiagnosed as psychosis. Despite these sources of bias, the findings support an emerging theoretical framework in which those immigrants most subject to discrimination, often because of their race, may be most vulnerable to onset of psychosis. Socioeconomic factors and trauma also likely play a role. Early intervention programs may increase their effectiveness by taking this into consideration. The findings also underline the significance of the federal role in health-care funding for refugees, a highly vulnerable population.

Anderson KK, Cheng J, Susser E, McKenzie KJ, Kurdyak P. Incidence of psychotic disorders among first-generation immigrants and refugees in Ontario. CMAJ. 2015;17:e279-e286. Article

Norclozapine, the metabolite of clozapine, may be more useful than you think

Although psychiatrists know that long-term disability in schizophrenia is related to negative and cognitive symptoms, our treatment goals often focus on positive symptoms. The unfortunate reason is that we lack good treatments for cognitive and behavioral deficits. Many antipsychotics have anticholinergic properties which we know can dull cognition or even cause delirium in sensitive patients, but we accept this risk in exchange for the benefit of eliminating psychosis.

Clozapine is highly anticholinergic but its metabolite, N-desmethylclozapine or norclozapine, has partial cholinergic agonist activity at muscarinic receptors. Although psychopharmacologists have suspected that this property of norclozapine may have cognitive benefits, most psychiatrists focus on optimizing clozapine serum level which is sometimes achieved by blocking clozapine metabolism with cytochrome enzyme inhibitors such as the antidepressant fluvoxamine. This increases the clozapine/norclozapine ratio; some evidence suggests this may reduce the metabolic burden of clozapine therapy (1). However, new evidence suggests that this may come at the price of worse cognitive performance, in particular working memory.

A team of researchers at the Centre for Mental Health and Addictions in Toronto examined the hypothesis that a greater ratio of clozapine to norclozapine would correlate with worse cognitive performance as measured by the Measurement and Treatment Research to Improve Cognition in Schizophrenia Consensus Cognitive Battery (MATRICS battery) (2).  They recruited 30 adults, mean age 38.6 years, on clozapine monotherapy for schizophrenia or schizoaffective disorder whose dose had been unchanged for at least 4 weeks. The subjects had blood taken for clozapine and norclozapine concentrations on the same day that they underwent PANSS rating and the MATRICS battery, which comprises 10 tests in 7 cognitive domains such as verbal learning, visual learning, working memory and processing speed.

In multiple regression analyses, the clozapine/norclozapine ratio was negatively correlated with performance on working memory but not with the other 6 cognitive domains. Working memory performance was not correlated with demographic variables or PANSS score, nor with either clozapine or norclozapine serum concentrations independently of each other.

The investigators suggest that the significance of the clozapine/norclozapine ratio reflects the opposing effects of the two molecules on muscarinic type 1 receptors, given that the cholinergic system is crucial for complex attentional processes as tested by working memory measures. They acknowledge that the MATRICS battery may not be sensitive enough to detect effects on other domains, and also that this is a cross-sectional study that cannot establish causation. Serial measurements in individuals as the clozapine/norclozapine ratio changes would be more conclusive.


1. Lu ML, Lane HY, Lin SK, Chen KP, Chang WH. Adjunctive fluvoxamine inhibits clozapine-related weight gain and metabolic disturbances. J Clin Psychiatry. 2004;65:766-771. Abstract

2. Rajji TK, Mulsant BH, Davies S, et al. Prediction of working memory performance in schizophrenia by plasma ratio of clozapine to N-desmethylclozapine. Am J Psychiatry. 2015;172:579-585. Abstract

Supersensitivity psychosis in treatment resistance

Guy Chouinard proposed the concept of dopamine supersensitivity psychosis (DSP) in 1978, a consequence of chronic antagonism of dopamine D-2 receptors which also is posited to cause tardive dyskinesia (1). The proposed mechanism is upregulation of D2 receptors in the basal ganglia, and tardive dyskinesia is itself considered one of the markers of the condition, also characterized by tolerance to increasing doses of antipsychotic. Supersensitivity psychosis patients may therefore represent a subtype of treatment resistance. In this study from Japan, the investigators examined this hypothesis in a group of patients with chronic psychosis (2).

The 147 patients enrolled had treatment-resistant schizophrenia or schizoaffective disorder as defined by failure of at least 2 antipsychotics at a dose equivalent to 600 mg chlorpromazine for 4 weeks. Although specifics of antipsychotic therapy were not provided, none of the patients was on clozapine. Their mean duration of illness was about 23 years. Supersensitivity was diagnosed if a patient met one of 3 criteria, which were adopted from Chouinard:

  • Antipsychotic tolerance indicated by relapse while on medication and failure to improve despite 20% or more increase in dosage
  • Rebound psychosis manifested by swift relapse with reduction or discontinuation of medication; the psychosis may involve new symptoms for a patient
  • Presence of tardive dyskinesia

The investigators found that 106 or 72.1% of the patients met at least one criterion for DSP; 56% had tolerance, 44% had tardive dyskinesia, and 42% had rebound psychosis. The patients were also classified by the presence or absence of deficit syndrome, defined by prominent negative symptoms assessed by standardized rating instruments. Of 55 patients judged to have deficit syndrome, the majority did not meet criteria for DSP; hence, DSP was significantly negatively associated with prominent deficit symptoms.

Although the researchers evaluated the present state of each subject, the main limitation of the study was reliance on chart reviews for the longitudinal course of patients’ illness. Furthermore, relapse of symptoms due to nonadherence could not be reliably distinguished from antipsychotic tolerance. The findings however suggest that supersensitivity psychosis may be an important contributor to treatment resistance, and that investigations using functional imaging and other techniques are warranted to validate the concept of DSP.

References Continue reading

High IQ predicts suicide in Israeli men with schizophrenia

Previous research has correlated lower intellectual ability with suicide. Using population-based registries in Israel, Dr. Mark Weiser of Tel Aviv University and colleagues examined the correlation of IQ with subsequent suicide in men, all of whom have cognitive testing at age 17 by the national draft board. The Israeli hospital registry allows determination of diagnoses in anyone who has inpatient treatment. Causes of death were determined by examining the Israeli vital statistics registry; only unambiguous suicides were included. According to Weiser, this probably underestimated suicides as some proportion of deaths with undetermined cause were likely suicides.

Dr. Mark Weiser at the 2015 International Congress  on Schizophrenia Research, Colorado Springs

Dr. Mark Weiser at the 2015 International Congress on Schizophrenia Research, Colorado Springs, USA

The researchers began with 930,589 consecutively tested men from draft board records but excluded those that had developed psychosis within a year of testing, those hospitalized for non-psychotic illness, and those with missing data, which left a final sample of 596,607 men. Of these, 2881 had been hospitalized subsequently for schizophrenia, and 566,726 men were controls who had had no psychiatric hospitalizations. During the follow-up of 10 years, 319 men in the control group and 25 in the schizophrenia group died by suicide. In men with schizophrenia, those with an IQ one standard deviation or more above the mean had an odds ratio (OR) of suicide of 4.5 (p < 0.001) compared with the reference group of men without schizophrenia and with average IQ. Men with schizophrenia and intelligence one standard deviation below the mean had an OR of suicide of 1.8. Dr. Weis said that 60% of suicides in the schizophrenia group occurred within 6 months of hospital discharge.

Mark Weiser, Ori Kapara, Nomi Werbeloff, Abraham Reichenberg, Rinat Yoffe, Eyal Fruchter, Keren Ginat, Michael Davidson. A population based longitudinal study of suicide risk in male schizophrenia: proximity to first admission and the moderating effect of premorbid IQ. Symposium 2-7, 15th International Congress on Schizophrenia Research, Colorado Springs, Colorado. March 29-April 1, 2015.

Exercise-associated hippocampal plasticity and hippocampal microvascular plasticity in chronic refractory schizophrenia patients

RANDALL - WIN_20150331_130356Donna Jane-Mai Lang, Alexander Rauscher, Allen E Thornton, Kristina Gicas Geoff Smith, Vina Goghari, Olga Leonova, Randall F White, Fidel Vila-Rodriguez, Wayne Su, Barbara Humphries, Aaron Phillips, William Honer, Alexandra Talia Vertinsky, Darren E Warburton. Poster presented at 15th International Congress on Schizophrenia Research, Colorado Springs, Colorado. March 29-April 1, 2015.


Background: Hippocampal deficits are a commonly reported finding in chronic schizophrenia patients, and may contribute to severity of illness. Regular exercise is thought to remediate both hippocampal volume reductions and neurovascular flow to this region.

Methods: Seventeen chronic refractory schizophrenia patients were enrolled in a 12-week exercise intervention trial. Clinical assessments (PANSS, SOFAS, Hamilton Anxiety Scale (HAMAS), Calgary Depression Scale, Extrapyramidal Symptom Severity Scale), physical assessments (BMI, resting heart rate (RHR), blood pressure (BP), VO2 Max) and 3T MRI data (3D structural MRI, susceptibility weighted imaging) were ascertained at baseline and 12 weeks. Repeated measures ANOVAs with total (L+R) hippocampal and total hippocampal venule volumes expressed as ratios to total brain volume and total hippocampal volume respectively. Additional correlational models were applied.

Results: Patients had a significant increase in total hippocampal volume after 12 weeks of exercise (F(1, 33) = 6.8, p. = 0.019. Total hippocampal venule volume was not significantly increased after exercise (F(1, 33) = 0.17), although the overall increase in venule volume was 7-7.5%. A significant positive relationship between absolute change in total hippocampal volume and absolute change in hippocampal venule volume was observed (r = .52, p. = 0.04). Patients exhibited reduced symptom severity (p. = 0.0005), improved social and occupational functioning (p. = 0.0004), and a strong trend for reduced depression severity (p. = 0.06) at the end of the 12-week exercise intervention. Measures of BMI, RHR, BP and VO2 Max were not statistically different at 12 weeks, however exploratory investigations revealed a potential, but statistically nonsignificant relationship between improved VO2 Max capacity and reduced HAMAS score (r = -.44, p. = .067).

Conclusion: We observed exercise-associated hippocampal volume increases after 12 weeks of regular exercise in chronic refractory schizophrenia patients, as was previously reported by Pajonk et al, 2010. Moreover, these changes in hippocampal volume were correlated to changes in hippocampal venule volumes. These data support the hypothesis that regular exercise offers remediation in both hippocampal tissue volume and hippocampal microvascular volume in chronically treated refractory patients. Relationships to other clinical measures still remain to be clearly established.

Prenatal Tobacco Exposure and Schizophrenia


In utero exposure to tobacco, in other words having a mother who smoked during pregnancy, has been associated with several developmental disorders including attention deficit disorder and learning problems. Research from the Finnish Prenatal Study of Schizophrenia, a nationwide cohort of people with schizophrenia, suggests a link between this illness and in utero tobacco exposure. Dr. Alan Brown of Columbia University in New York described 997 Finnish patients with schizophrenia matched with same-sex and same-age controls whose mothers had blood samples taken during pregnancy. The American and Finnish research team examined serum cotinine, a metabolite of nicotine and a reliable biomarker for tobacco use, in the banked blood samples.
Among the affected offspring, 20.2% were born to women with serum cotinine greater than 50 ng/ml, considered a sign of high tobacco use, compared with 14.7% of controls; the odds ratio was 1.38 (95% CI, 1.05-1.82, p = 0.02), with adjustment for maternal age, parental psychiatric disorder, and birth province. When serum cotinine was analyzed as a continuous variable, the effect was weaker, with a final odds ratio of 1.06 (CI, 1.004-1.12; p = 0.035) when adjusted for the same factors along with a measure of maternal inflammation, C-reactive protein (CRP), which was also determined in banked serum.
The findings, while far from conclusive, suggest a dose-response which is one sign of plausibility. Furthermore, nicotine crosses the placenta and is associated with neurodevelopmental effects including cortical thinning and changes in the P1 auditory evoked response. The physiologic mechanisms of smoking may include reduced placental perfusion, increased carbon monoxide, oxidative stress, and the direct effects of nicotine on nicotinic acetylcholine receptors, which are important regulators of other neurotransmitters, and of neuron migration and cell survival.
A. Brown, H. Surcel, S. Niemela, S. Hinkka-Yli-Salomäki, I. W. McKeague, A. Sourander. Epidemiological Evidence for Inflammation and Nicotine Exposure as Prenatal Risk Factors for Schizophrenia. Symposium 1-2, 15th International Congress on Schizophrenia Research, Colorado Springs, Colorado. March 29-April 1, 2015.

Riverview Refractory Psychosis Data Presented at International Psychiatry Congress



View the poster in a PDF file here


Treatment-resistant psychosis is a challenge to psychiatry and a substantial burden to health-care systems. The province of British Columbia in Canada has publicly funded, universal health care, and patients with treatment-resistant psychosis may receive care in a specialized residential program. Between 1993 and 2011, 663 patients were admitted to this program; this cohort contains one of the largest known series of patients with treatment-resistant schizoaffective disorder.

All patients were evaluated by a psychiatrist, social worker, pharmacist, nurse, general physician, and neuropsychologist. Records from previous hospital admissions were reviewed and all information was presented at a multidisciplinary conference. This resulted in a consensus DSM-III or -IV multiaxial diagnosis and a detailed treatment plan. Ratings of symptoms and functioning at admission and discharge included the Positive and Negative Syndrome Scale (PANSS), the Global Assessment of Functioning Scale, the Social and Occupational Functioning Scale, and the Clinical Global Impression of Severity. A research psychologist compiled all data at the time of each patient’s hospitalization.

Patients who did not complete treatment or had a diagnosis other than schizophrenia (SZ), schizoaffective (SZA) or mood disorder (MD) were excluded; the following describes 551 included patients (SZ = 63%, SZA = 29%, MD = 8%). More than half were male (59%), and the mean duration of hospitalization was 30 weeks. The proportion receiving clozapine increased from 21% at admission to 61% at discharge. Those with a MD were less likely to receive clozapine than either SZ or SZA (SZ = 64%, SZA = 61%, MD = 41%). In each diagnostic group, both antipsychotic polypharmacy and the ratio of prescribed daily dose to defined daily dose (PDD/DDD) of antipsychotic medication decreased during hospital stay (polypharmacy: SZ: 52% to 16%, SZA: 52% to 14%, MD: 43% to 0%; PDD/DDD: SZ: 2.1 to 1.6, SZA: 2.1 to 1.4, MD: 1.6 to 1.1). The use of mood stabilizers declined in all groups, but antidepressant use declined only in SZ and SZA. Mean total PANSS score declined in all diagnostic groups, but most in MD, least in SZ, and intermediate in SZA.

In an intensive inpatient program for treatment-resistant psychosis, aggregate improvement occurred despite global reduction in medications while clozapine use nearly tripled. Lower total antipsychotic dose correlated with greater improvement at discharge.

Could grey matter loss in the superior temporal gyrus contribute to treatment resistance?

The DSM 5 abandoned classifying schizophrenia by psychopathology subtype, but the heterogeneity of the disorder still requires explanation. A more pragmatic approach advocated by some researchers is classification according to treatment response: antipsychotic responsive, clozapine responsive, and clozapine non-responsive. Investigators are looking at the biologic correlates of these subtypes, and a group from New Zealand recently examined differences in brain volume. Using a 3-Tesla scanner, they obtained T1-weighted images of the brains of 18 antipsychotic responders, 19 clozapine responders (for whom other antipsychotics failed), 15 clozapine nonresponders, and 20 controls. All subjects were 18 to 45 years old, and patients with neurologic or active addictive disorders were excluded. The clozapine responsive and non-responsive patients had failed to respond to at least two trials of other antipsychotics, and the PANSS was used to assess symptoms.

The groups of patients did not differ by mean age, PANSS scores or illness duration. The groups had some differences in substance use history; the clozapine-resistant patients had more use of hallucinogens, and the antipsychotic responsive group had more use of cannabis, but the groups did not differ in stimulant use history.

Compared with controls, all patient groups had a reduction in whole-brain and white-matter volumes, and the clozapine-resistant group had a significant increase in ventricular volume. The treatment-resistant and clozapine-resistant patients had smaller grey matter volumes compared with controls and antipsychotic-responsive patients. In analysis using voxel-based morphometry, a technique to examine the volume of specific brain regions, the clozapine-resistant patients, compared with controls, showed bilateral grey matter reductions in the superior and middle temporal gyri, ventromedial prefrontal cortex, anterior cingulate gyrus, and postcentral gyrus. The left cerebellum and right occipital cortex also showed grey matter reduction. Compared with controls, the treatment-resistant group had a similar magnitude of grey matter volume reduction which especially affected the right perisylvian region.

Compared with the antipsychotic-responsive group, both clozapine-resistant and clozapine-responsive groups had reduction in grey matter volume with somewhat differing patterns. Only the clozapine-resistant patients had a relative reduction in the left cerebellum and left anterior cingulate gyrus. No differences were seen in comparing the clozapine-resistant and clozapine-responsive groups.

A controversy in the field of neuroimaging of schizophrenia is the role of antipsychotic exposure in cerebral volume loss; previous research has shown conflicting results. In this study, the clozapine-resistant group had a higher mean daily dose of antipsychotic compared with the other groups, but the researchers found no overall correlation between daily dose and grey matter volume. The study did not look at lifetime antipsychotic exposure.

The investigators highlight the finding of prominent volume reduction in the superior temporal gyrus in the clozapine-resistant group, which was seen in a number of prior studies including longitudinal investigations and in first-episode patients. This brain structure is crucial for auditory processing and language, which are highly implicated in schizophrenia; perhaps tissue loss in this region contributes to poor medication response. However, as the researchers state, in this kind of observational study we are unable to draw conclusions about cause and effect.

Anderson VM, Goldstein ME, Kydd RR, Russell BR. Extensive grey matter volume reduction in treatment-resistant schizophrenia. Int J Neuropsychopharmacol. Published online Feb 25, 2015. Abstract