Showing papers in "Archives of General Psychiatry in 1977"
TL;DR: The evidence for differing rates of depression between the sexes in the United States and elsewhere during the last 40 years is reviewed, and the various explanations offered are critically analyzed.
Abstract: • This article reviews the evidence for differing rates of depression between the sexes in the United States and elsewhere during the last 40 years, and then critically analyzes the various explanations offered. These explanations include the possibility that the trends are spurious because of artifacts produced by methods of reporting symptoms, or that they are real because of biological susceptibility (possibly genetic or female endocrine), psychosocial factors such as social discrimination, or female-learned helplessness.
1,811 citations
TL;DR: This study reports on an instrument that has been developed for collecting information concerning family history and that provides criteria for 12 diagnoses--the Family History-Research Diagnostic Criteria.
Abstract: • Data concerning familial history of psychiatric disorders are often used to assist in diagnosis, to examine the role of genetic or nongenetic familial factors in etiology, or to develop new methods of classification. Information concerning familial prevalence may be collected by two different methods: the family history method (obtaining information from the patient or a relative concerning all family members), and the family study method (interviewing directly as many relatives as possible concerning their own present or past symptomatology). This study compares these two methods. In general, the family study method is preferred since information is likely to be more accurate. The family history method leads to significant underreporting, but this can be minimized through the use of diagnostic criteria. This study reports on an instrument that has been developed for collecting information concerning family history and that provides criteria for 12 diagnoses—the Family History-Research Diagnostic Criteria. Using diagnostic criteria leads to greater sensitivity, but underreporting remains a major problem of the family history method.
1,782 citations
TL;DR: A prospective, five-year follow-up using reliable evaluation techniques to determine whether specific relations between predictors and outcome variables represent behavior patterns persisting over an extended period demonstrates the prognostic importance and specificity of certain predictors over five years.
Abstract: † Recent studies of schizophrenia have begun to demonstrate the complex nature of its outcome characteristics and their predictors. However, generalization of findings has been limited by methodological problems such as relatively short-term followup, the use of retrospective data, or employment of evaluation techniques without demonstrated reliability. This report describes a prospective, five-year follow-up using reliable evaluation techniques to determine whether specific relations between predictors and outcome variables represent behavior patterns persisting over an extended period. Results demonstrate the prognostic importance and specificity of certain predictors over five years. These results support the view that outcome function is comprised of persisting open-linked systems of behavior.
499 citations
TL;DR: Experimental evidence is reviewed, which uses the human platelet model to investigate neurotransmitter-related abnormalities in Down syndrome, mental retardation, infantile autism, hyperactivity syndromes, schizophrenia, affective disorders, Duchenne muscular dystrophy, Parkinson disease, Huntington chorea, and migraine headaches.
Abstract: • Comparison of the properties of blood platelets and serotonergic synaptosomes suggests that the human platelet can serve as an appropriate model for the transport, metabolism, and release of serotonin (5-HT) by CNS serotonergic neurons. The study of blood 5-HT levels and platelet 5-HT pharmacodynamics in patients with a variety of psychiatric and neurologic disorders has generated interesting leads into possible abnormalities of CNS 5-HT neurons in these patients. This article reviews the experimental evidence, which uses the human platelet model to investigate neurotransmitter-related abnormalities in Down syndrome, mental retardation, infantile autism, hyperactivity syndromes (minimal brain dysfunction), schizophrenia, affective disorders, Duchenne muscular dystrophy, Parkinson disease, Huntington chorea, and migraine headaches.
385 citations
TL;DR: Several tricyclic antidepressants have been assessed for their potency in binding to the muscarinic acetylcholine receptor of brain and intestine, with implications for their use in patients who might be affected adversely by anticholinergic effects.
Abstract: Several tricyclic antidepressants have been assessed for their potency in binding to the muscarinic acetylcholine receptor of brain and intestine. Amitriptyline hydrochloride is about ten times as potent as imipramine hydrochloride. Dimethylated drugs are more potent than monomethylated ones. The relative anticholinergic activities of tricyclic antidepressants have implications for their use in patients who might be affected adversely by anticholinergic effects.
382 citations
TL;DR: Data from this study are consistent with the hypothesis that there is a strong relationship between anorexia nervosa and affective disorder.
Abstract: • Follow-up data on 26 patients hospitalized during adolescence for anorexia nervosa are presented. The mean length of follow-up was 4.9 years. There were no mortalities. Only one patient at the time of follow-up was still possibly anorexic. However, a substantial number of the patients did have other eating difficulties. Most striking was the clinical psychopathology present at follow-up, particularly the incidence of affective disorder. A large number of the patients manifested depressive symptomatology in both the premorbid and the postmorbid states, as well as at the time of follow-up. A family history of affective disorder was particularly common in the mothers of the anorexic patients. Data from this study are consistent with the hypothesis that there is a strong relationship between anorexia nervosa and affective disorder.
337 citations
TL;DR: The erections of rapists and nonrapists were measured during audio descriptions of rape and nonrape sexual scenes to discriminate those rapists with the highest frequency of rape, those who had injured their victim, and those who chose children as victims.
Abstract: • The erections of rapists and nonrapists were measured during audio descriptions of rape and nonrape sexual scenes. On the basis of their erection measures, rapists were separated from nonrapists in that the former developed erections to rape descriptions while the latter did not. The method also discriminated those rapists with the highest frequency of rape, those who had injured their victim, and those who chose children as victims.
332 citations
TL;DR: There was a significant lowering of morbidity in the intervention group as compared to the control group (P less than .02), and the most significant impact of intervention occurred with the subgroup of intervention and control subjects who perceived their social networks as very nonsupportive during the bereavement crisis.
Abstract: • To study the effectiveness of preventive intervention in lowering postbereavement morbidity, 200 widows were assessed in the early weeks following their husbands' deaths. Subjects at risk for postbereavement morbidity were selected and randomly allocated to experimental (N = 31) and control (N = 33) groups. Specific support for grief and encouragement of mourning was carried out with the experimental group during the first three months; no intervention was given to the control group. All were followed up 13 months later with a validated health questionnaire. There was a significant lowering of morbidity in the intervention group as compared to the control group ( P P
324 citations
TL;DR: A map of variations of families and some of the core relationships between types of family and the mental health of children are provided, finding family type was found to be strongly related over time to the child's social adaptational status (SAS) and his or her psychological well-being.
Abstract: • This study provides a map of variations of families and some of the core relationships between types of family and the mental health of children. Family types in a poor, black urban community were defined in terms of the adults present at home. The resulting taxonomy is based on two populations: half of the community's 1964 first-grade children and families and the entire 1966 first-grade children and families. Eighty-six family types were found, falling into ten major classes. Family type was found to be strongly related over time to the child's social adaptational status (SAS) and his or her psychological wellbeing. The results suggest that (1) mother alone families entail the highest risk in terms of social maladaptation and psychological well-being of the child; (2) the presence of certain second adults has important ameliorative functions—mother/grandmother families being nearly as effective as mother/father families, with mother/stepfather families similar to mother alone in regard to risk; and (3) the absence of the father was less important than the aloneness of the mother in relation to risk.
292 citations
TL;DR: There was a statistically and clinically significant relationship between plasma levels and response and this relationship existed across the entire sample, and was accentuated when the bipolar and unipolar nondelusional populations were examined.
Abstract: • Sixty depressed nonschizophrenic patients were admitted to a research unit. Following one drug-free week and one week of placebo, patients received 3.5 mg/kg of imipramine hydrochloride for 28 days. Plasma levels of imipramine and its metabolite desipramine hydrochloride (desmethylimipramine) were measured three times weekly and the relationship between plasma steady-state levels and clinical outcome was examined. Steadystate levels ranged from 50 to 1,050 ng/ml. There was a statistically and clinically significant relationship between plasma levels and response. The relationship existed across the entire sample, and was accentuated when the bipolar and unipolar nondelusional populations were examined. Because a strong relationship between sex and outcome was observed, the unipolar nondelusional patients were stratified by sex and a significant relationship still persisted. Only the unipolar delusional patients failed to demonstrate an association between blood level and clinical response. ( Arch of Gen Psychiatry 34:197-204, 1977)
283 citations
TL;DR: Preschizophrenic infants show a fluctuating dysregulation of maturation that involves physical growth; gross motor, visual-motor, and cognitive development; proprioceptive and vestibular responses; muscle tone; and possibly arousal.
Abstract: • In chronic schizophrenics, disordered motor development in childhood is followed by more early cognitive and social impairment and poorer outcome; childhood schizophrenics represent the most extreme variants of this. Preschizophrenic infants show a fluctuating dysregulation of maturationm—or "pandevelopmental retardation" (PDR)m—that involves physical growth; gross motor, visual-motor, and cognitive development; proprioceptive and vestibular responses; muscle tone; and possibly arousal. Pandevelopmental retardation was significantly related to a genetic history for schizophrenia (
TL;DR: In this article, the primary alcoholics as a group reported a greater incidence of familial alcohol abuse than the psychiatric subjects, but a difference on this factor was not observed between the primary and secondary subgroups.
Abstract: • Alcoholics were differentiated into two subgroups on the basis of drinking patterns and subjective response to alcohol. Severe drinkers (primary alcoholics) retrospectively reported more symptoms of childhood minimal brain dysfunction than less severe drinkers (secondary alcoholics), psychiatric patients, and normals. The alcoholics as a group reported a greater incidence of familial alcohol abuse than the psychiatric subjects, but a difference on this factor was not observed between the primary and secondary subgroups. In terms of clinical status, the primary alcoholics presented Minnesota Multiphasic Personality Inventory profile more indicative of normality than the other groups, but scored significantly higher on the MacAndrew Alcoholism Scale. These findings are discussed in light of further delineating a specific subtype of alcoholism that may have a genetic-constitutional relationship with other pathological disorders.
TL;DR: Preliminary experiments were carried out to determine whether or not morphine-like substances in blood could be treated with synthetic β-endorphin, and this preliminary report describes initial observations.
Abstract: Recent and exciting research in animals has described endogenous polypeptides, endorphins, which in many biological respects resemble opiate agonists. 1-3 While behavioral effects in animals are under intense investigation, the effects of the pure endorphins in man require specific testing. The effect of opiate antagonists in schizophrenic patients 4 are in some dispute, but a recent doubleblind study revealed no effects. 5 Thus, direct measures of injected endorphins are relevant to understanding their effects in man. Accordingly, when the opportunity presented itself, it seemed logical to evaluate synthetic β-endorphin in schizophrenic and depressed patients, and this preliminary report describes our initial observations. Thirty milligrams of synthetic material was prepared by one of us (C. H. L.) and made available for this purpose; subsequently, a second batch was used. 6 SUBJECTS AND METHODS Laboratory Procedures Preliminary experiments were carried out to determine whether or not morphine-like substances in blood could
TL;DR: Drug treatment tended to improve ability to sustain set, to increase efficiency of selective attention, and to increase rate of information processing in chronic schizophrenics, and clinical improvement was correlated with reduction in attentional dysfunction.
Abstract: This study examined the effects of phenothiazine treatment on attentional-perceptual, cognitive, and psychophysiological dysfunction in chronic schizophrenics. Under double-blind conditions, 20 patients receiving chlorpromazine and 20 receiving placebo for eight weeks were tested by performance measures, clinically rated, and monitored for skin resistance and heart rate on four occasions. Phenothiazine effects on measures of attention-perception and on psychophysiological response were demonstrable, but not on tests and ratings of cognitive dysfunction. The direction of effects was toward normalization of function. Drug treatment tended to improve ability to sustain set, to increase efficiency of selective attention, and to increase rate of information processing. Autonomic reactivity was reduced and a deactivation effect suggested. Clinical improvement was correlated with reduction in attentional dysfunction. The results are discussed in terms of their implications for hypothesized behavioral mechanisms of drug action, primary "behavioral site" of drug action, therapeutic response measurement, and functional theories of schizophrenic psychopathology.
TL;DR: A test of sustained attention (the Continuous Performance Test) was administered to a group of children at risk for the eventual manifestation of schizophrenia and to a groups of "normal control" children.
Abstract: • A test of sustained attention (the Continuous Performance Test) was administered to a group of children at risk for the eventual manifestation of schizophrenia and to a group of "normal control" children. Differences in performance between the two groups were attributable to poorer discriminability on the part of the high-risk subjects.
TL;DR: No evidence is found that patients with good signs are not in need of drugs; instead they profit most from drug treatment, and it is recommended that a therapy such as MRT be deferred until the patient is essentially asymptomatic.
Abstract: • Despite the established efficacy of neuroleptics for maintaining schizophrenics in the community, there are data suggesting that those with very good prognostic signs may do as well without drugs. In testing this, we find no evidence that patients with good signs are not in need of drugs; instead they profit most from drug treatment. Patients who benefit little (1) are men whose families were disrupted earlier in their lives, (2) live alone or with extended families whose attitudes toward the study are not positive, and (3) are irregular in taking their medication. The practical implication is that the drug nonresponder can be helped by some means to ensure regularity of medication taking, such as a visiting nurse or long-acting medication. A second research question is whether major role therapy (MRT, a combination of social casework and vocational rehabilitation) can lengthen the time until relapse. Major role therapy affected time to relapse in a disordinal manner; asymptomatic patients benefited from MRT, while in patients with greater symptom severity MRT—surprisingly—hastened relapse. It is hypothesized that symptomatic patients are suffering from an inability to manage an expanded and enriched cognitive field; MRT, a therapy that urges the patient to become more responsible and to expand his horizons, may actually induce a state with which the patient cannot cope. It is recommended that a therapy such as MRT be deferred until the patient is essentially asymptomatic.
TL;DR: Oral tryptophan administration doubled urinary 5-HIAA excretion in both groups and raised urinary5-HT levels in hyperserotonemic autistic children, but lowered urinary 5,HT in mildly retarded, normal blood 5-HT children.
Abstract: • Mean whole blood serotonin (5-HT) levels were elevated in groups of autistic and severely retarded children. Eight of 27 (30%) individual autistic children, 13 of 25 (52%) severely retarded children, two of 23 (9%) mildly retarded children, and none of the control children had statistically significant blood 5HT levels elevations (hyperserotonemia). Hyperserotonemic autistic children excreted more urinary 5-HT, 5-hydroxyindoleacetic acid (5-HIAA), tryptamine, and vanillylmandelic acid than did mildly retarded children with normal blood 5-HT levels. Rates of depletion and repletion of blood 5-HT levels in these two groups following reserpine therapy were identical. Oral tryptophan administration doubled urinary 5-HIAA excretion in both groups and raised urinary 5-HT levels in hyperserotonemic autistic children, but lowered urinary 5-HT in mildly retarded, normal blood 5-HT children. No clear mechanism for hyperserotonemia was found; the rationale for further investigations is discussed.
TL;DR: This article found that the daughters of alcoholics had no more depression than controls, indicating that alcoholism in the biological parents did not increase the risk of depression in daughters raised by foster parents.
Abstract: • Forty-nine daughters of alcoholics were compared to 47 daughters of nonalcoholics; both groups of women (average age, 35 years) had been adopted by nonrelatives early in life. Two women in each group were alcoholic or problem drinkers. Although this is above the expected rate of alcoholism among women, the numbers are too small to draw definite conclusions. Almost all were light drinkers. Daughters of alcoholics had no more depression than controls, indicating that alcoholism in the biological parents did not increase the risk of depression in daughters raised by foster parents. Environmental factors may be important in both alcoholism and depression in women, since both tended to be correlated with psychopathology in the foster parents.
TL;DR: The syndrome had a gradual onset, responded slowly to withdrawal of the neuroleptic or use of an anticholinergic agent, but seemed to respond more rapidly to amantadine.
Abstract: • Eight patients developed a syndrome marked by features of catatonia (including posturing, waxy flexibility, withdrawal and regression) and parkinsonism (including bradykinesia and rigidity) while receiving high-potency neuroleptic drugs. The syndrome had a gradual onset, responded slowly to withdrawal of the neuroleptic or use of an anticholinergic agent, but seemed to respond more rapidly to amantadine. The syndrome may easily be confused with a worsening of schizophrenic symptoms.
TL;DR: The sympathetic nervous system was evaluated in primary autistic patients and their families and found that norepinephrine levels were higher in the patients than in age-controlled normal volunteers both while supine and after standing.
Abstract: • The sympathetic nervous system was evaluated in 11 primary autistic patients and their families. The plasma levels of norepinephrine (NE), the neurotransmitter of the sympathetic nervous system, was higher in the patients than in age-controlled normal volunteers both while supine and after standing. The plasma activity of dopamine-β-hydroxylase, the enzyme that converts dopamine to NE, was significantly lower in the autistic patients and their healthy relatives than in control groups. Dopamine-β-hydroxylase does not appear to provide an index of sympathetic activity in this group of patients who, on the basis of the elevated plasma levels of NE, may demonstrate a chronic state of hyperactivity of the sympathetic nervous system. Low enzyme activity found in both the autistic patients and their immediate families may be associated with this disorder.
TL;DR: Findings show that secondary depression in ambulatory patients with other psychiatric disorders is relatively common, and the symptom patterns of secondary depressives are similar to primary depressives but are overall less severe.
Abstract: • The primary-secondary distinction in affective disorders has been proposed to reduce the heterogeneity of depression. An investigation of the frequency of secondary depression and its nature in depressed opiate addicts, alcoholics, and schizophrenics was undertaken. Findings show that secondary depression in ambulatory patients with other psychiatric disorders is relatively common. The sociodemographic characteristics of the secondary depressives are consistent with the population from which they derive but differ from primary depressives. The symptom patterns of secondary depressives are similar to primary depressives but are overall less severe. These findings give further support to the value of separating out secondary from primary depression in future research studies.
TL;DR: No relationship was found between handedness and eye dominance either in the schizophrenic or the normal groups, which questions the assumption that eyedness-handedness nonconcordance is a pathological sign.
Abstract: • Two hundred schizophrenics were compared to 200 normal controls on a measure of laterality that included handedness, footedness, and eye dominance scales. Schizophrenics showed more left-sidedness on the laterality score. The established relationship between motoric and cognitive aspects of functional brain asymmetry, found in neurological and normal populations, suggests that the leftward tendency of schizophrenics may be manifested in cognitive and conative functions as well. These results seem to corroborate previous findings indicating that schizophrenia might be related to left hemisphere dysfunction. No relationship was found between handedness and eye dominance either in the schizophrenic or the normal groups. This finding questions the assumption that eyedness-handedness nonconcordance is a pathological sign.
TL;DR: In a study of remitted, non-psychotic schizophrenics, the relapse rate within one year was significantly higher for those patients taking placebo as opposed to those taking fluphenazine hydrochloride orally or FLU decanoate as discussed by the authors.
Abstract: • In a sample of remitted, nonpsychotic schizophrenics, the relapse rate within one year was significantly higher for those patients taking placebo as opposed to those taking fluphenazine hydrochloride orally or fluphenazine decanoate. There were no differences in relapse rates between the two active drugs, but there were significantly more terminations due to toxicity from fluphenazine decanoate than from fluphenazine given orally, entirely due to the fact that in 35% of patients receiving fluphenazine decanoate, severe akinesia developed.
TL;DR: There is increased brain MAO activity during late childhood and adolescence, and this activity is significantly higher in women than men, consistent with previous evidence suggesting that age and sex are important determinants of amine metabolism in the human central nervous system.
Abstract: • Norepinephrine (NE), dopamine (DA), tyrosine hydroxylase (TH), catechol-O-methyltransferase (COMT) and monoamine oxidase (MAO) levels were measured in human brain tissue obtained at autopsy from a series of 39 patients dying of various medical and accidental causes. The nine following brain areas were studied: globus pallidus, thalamus, hypothalamus, hippocampus, substantia nigra, floor of the fourth ventricle, orbital cortex, caudate nucleus, and mammillary bodies. Enzyme activity correlated positively with age in all brain areas for MAO (with both benzylamine and tryptamine substrates) but no consistent pattern of correlation was found for COMT and TH. Mean MAO activity was significantly higher in women than men. There is increased brain MAO activity during late childhood and adolescence. These data are consistent with previous evidence suggesting that age and sex are important determinants of amine metabolism in the human central nervous system.
TL;DR: Three basic methodological issues are raised, including: importance of structured interviews and objective diagnostic criteria, the importance of a test/retest vs an interviewer/observer design, and the calculation of reliability in a way that takes chance agreement into account.
Abstract: • This article reviews some methodological aspects of studies of diagnostic reliability in psychiatry. We define and discuss the concept of interrater reliability and review some of the ways in which the design of the reliability study can influence the results. Three basic methodological issues are raised, including: the importance of structured interviews and objective diagnostic criteria, the importance of a test/retest vs an interviewer/ observer design, and the calculation of reliability in a way that takes chance agreement into account.
TL;DR: Daughters of alcoholics, adopted and nonadopted, had a higher rate of alcoholism than was the expected frequency in the general population, but so did controls in the adopted group; neither group had higher rates of other psychopathology, eg, depression; however, daughters ofalcoholics raised by their biological parents had significantly more depression.
Abstract: • This report completes a series of studies conducted in Denmark comparing drinking patterns and psychopathology in adopted and nonadopted children of alcoholics. Sons of alcoholics had higher rates of alcoholism than controls, whether raised by their alcoholic parents or by foster parents. They did not have more psychopathology otherwise. Daughters of alcoholics, adopted and nonadopted, had a higher rate of alcoholism than was the expected frequency in the general population, but so did controls in the adopted group; neither group had higher rates of other psychopathology, eg, depression. However, daughters of alcoholics raised by their biological parents had significantly more depression.
TL;DR: Analysis of the after care experience of 374 schizophrenic patients treated with drug or placebo reveals that while the risk of relapse does decline substantially, it remains twice as high for placebo- treated patients than drug-treated patients even after two years of treatment.
Abstract: • The potential for unwanted side effects, particularly tardive dyskinesia, following long-term aftercare maintenance with antipsychotic medication has led to serious questioning of its continued use for schizophrenic patients. Does the risk of relapse decline with the passage of time? If so, is the advantage of drug therapy sustained and large enough to justify continued treatment beyond one or two years? More appropriate methods for analyzing the aftercare experience of 374 schizophrenic patients treated with drug or placebo reveals that while the risk of relapse does decline substantially, it remains twice as high for placebo-treated patients than drug-treated patients even after two years of treatment. The prophylactic effect of maintenance chemotherapy appears to be one to two times larger than generally estimated by the less precise "cumulative percentage" method.
TL;DR: In a study of interrater diagnostic reliability, 101 psychiatric inpatients were independently interviewed by physicians using a structured interview and diagnostic agreement was found to be high, despite the fact that in most previous investigations diagnoses were not made independently.
Abstract: • In a study of interrater diagnostic reliability, 101 psychiatric inpatients were independently interviewed by physicians using a structured interview. Newly admitted patients were randomly selected and examined by one of three psychiatrists. A second psychiatrist reexamined the same patient about 24 hours later. Interviews from the two examinations were evaluated independently, and diagnoses were made on the basis of objective criteria. The degree of diagnostic agreement for the two examinations was calculated using the kappa statistic. Agreement was found to be high as compared to other studies in the psychiatric literature, despite the fact that in most previous investigations diagnoses were not made independently. The results were also compared to studies of reliability of medical judgments. Possible reasons for the high interrater reliability are discussed and include the use of a structured interview and objective diagnostic criteria.
TL;DR: The cumulative evidence would appear to establish more firmly a winter and spring seasonality of schizophrenic births in northern Europe and the eastern United States.
Abstract: • The birth months of persons later diagnosed as schizophrenic were studied. Data were collected from 19 states on 53,584 schizophrenics born between 1920 and 1955. The controls were the general births in the same states for the same years. A highly significant peak in schizophrenic births was found from December to May, most marked in March and April. The seasonality was stronger in New England and the Midwest than in the South. Previous studies of schizophrenic births are also reviewed. The cumulative evidence would appear to establish more firmly a winter and spring seasonality of schizophrenic births in northern Europe and the eastern United States. Selection of patients, nutritional factors, environmental factors, genetic factors, and infectious agents are discussed as possible etiological explanations.
TL;DR: The relaxation therapy group showed a significant reduction in blood pressure postreatment compared with the nonspecific therapy and medical treatment only groups, even when those patients whose medication was increased were excluded from the data analysis.
Abstract: • Thirty-one patients receiving medical treatment for essential hypertension were randomly distributed into three groups: (1) relaxation therapy, (2) nonspecific therapy, and (3) medical treatment only. The nonspecific therapy group spent the same amount of time with the therapists as the relaxation group but was not given a specific therapy. Blood pressures were measured at a different time and in a different place from the behavioral treatments. The relaxation therapy group showed a significant reduction in blood pressure posttreatment compared with the nonspecific therapy and medical treatment only groups, even when those patients whose medication was increased were excluded from the data analysis. At follow-up six months posttreatment, the relaxation group showed a slight decrement in treatment effects, while both the nonspecific therapy and medical treatment only groups showed continued improvement; thus, there was not a significant difference between groups.