Supplemental Information
Supplemental Table 1. Parallel group analysis patient medication breakdown
Supplemental Table 1
Characteristics
Antipsychotics (number)
amisulpride
aripiprazole
clozapine
haloperidol
olanzapine
paliperidone
quetiapine
risperidone
ziprasidone
zuclopenithixol
amisulpride/clozapine
amisulpride/risperidone
ariprazole/clozapine
clozapine/haloperidol
clozapine/paliperidone
clozapine/chlorpromazine
olanzapine/paliperidone
olanzapine/risperidone
olanzapine/zuclopenithixol
paliperidone/quetiapine
quetiapine/risperidone
quetiapine/ziprasidone
quetiapine/zuclopenithixol
Antidepressants (numbers)
citalopram
clomipramine
desvenlaxafine
doxepin
duloxetine
escitalopram
fluoxetine
lithium
setraline
sodium valproate
venlaxafine
citalopram/lithium
escitalopram/ lithium
escitalopram/mirtazapine
fluoxetine/sodium valproate
paroxetine/sodium valproate
sodium valproate/venlaxafine
Benzodiazepines^ (numbers)
N
Placebo first
39
N
Raloxifene first
40
2
2
10
0
6
2
1
4
1
2
3
0
1
1
2
0
0
0
0
1
0
0
1
14
1
1
11
1
3
1
2
6
1
1
3
1
1
0
0
1
1
1
1
0
1
1
1
19
2
1
1
0
1
2
2
1
0
2
0
0
1
0
1
0
0
1
2
0
0
1
0
1
1
0
6
1
1
1
1
1
0
1
2
5
^Benzodiazepines included diazepam, temazepam, oxazepam, and lorazepam
1
Supplemental Table 2. Demographic, Cognitive, and Symptom Characteristics of
Healthy Controls
Supplemental Table 2
Characteristics
Age
Education
Sex (number)
N
Controls
87
31.9 (8.3)
87
87
14.6 (2.3)
46
41
male
female
87
Race (number)
69
12
2
4
Caucasian
Asian
Caucasian/Asian
Other
Baseline Scores
WAIS-III
WTAR
87
87
107.0 (14.5)
108.1 (8.8)
87
87
87
70
87
10.9 (2.9)
11.9 (3.4)
10.4 (3.6)
25.6 (8.7)
42.2 (11.3)
Cognitive Tests
WAIS-LNS
WMS-LM I
WMS-LM II
TMT-A
COWAT
Symptom Tests
PANSS
Positive
Negative
General
Total
n/a
n/a
n/a
n/a
DASS
SF-36v2 Total
SQLS Total
Depression 81
Anxiety 81
Stress 81
81
81
3.6 (5.5)
2.9 (4.1)
6.7 (7.8)
140.9 (10.7)
23.2 (11.2)
Unless otherwise specified, numbers refer to means and SD in parenthesis
WAIS-III Wechsler Adult Intelligence Scale, WTAR Wechsler Test of Adult
Reading,WAIS- LNS Letter Number Sequencing, WMS-LM I Wechsler
Memory Scale Logical Memory I,WMS- LM II Wechsler Memory Scale
Logical Memory II, TMT-A trail making test A, COWAT Controlled Oral
Word Association Test, PANSS Positive and Negative Syndrome Scale, DASS
Depression Anxiety and Stress Scale, SF-36v2 Short Form 36 Version 2
Health Survey Questionnaire, SQLS Schizophrenia Quality of Life Scale.
2
Supplemental Table 3. Crossover hormone and coagulation panel changes with raloxifene versus placebo treatment
Supplemental Table 3
N
Reference Ranges
Hormone Panel
Luteinizing Hormone
Follicle Stimulating Hormone
Coagulation Panel
Prothrombin Time
International Normalised Ratio
Antithrombin III
M/F
Placebo
Mean
Mean
Difference Difference
(SD)
(SD)
M
F
-0.5 (1.6)
1.5 (8.3)
-0.7 (1.2)
0.4 (3.4)
M [0-10]/ F [0-84] mIU/ml
M [0-12]/ F [0-90] mIU/ml
44/27
43/27
M/F [12-15] sec
M/F [0.8-1.1]
M/F [80-135 %]
36/16 -0.2 (0.6)
0.1 (0.4)
43/26 -0.03 (0.09) 0.00 (0.08)
39/24
0.9 (5.9)
2.0 (23.9)
Raloxifene
Mean
Mean
Difference Difference
(SD)
(SD)
M
F
0.6 (2.1)
2 (7.1)
1.0 (1.4)
1.9 (6.4)
0.3 (0.5)
0.04 (0.08)
-8.0 (7.9)
0.1 (0.6)
0.02 (0.05)
-6.8 (21.8)
Condition Condition*Sex
p-value
p-value
0.44
p<0.01
0.73
0.80
0.08
0.02
0.02
0.12
0.08
0.99
A review of changes on blood panel measures, including the coagulation panel, did not generally show any clinically relevant blood
changes, however, one patient who appeared normal at baseline showed a 48% decline in Antithrombin III after raloxifene treatment,
which returned to normal in follow-up blood work 6 weeks later.
3
Supplemental Table 4. Period effects
Supplemental Table 4
Period I
Mean Difference
(SD)
Period II
Mean Difference
(SD)
Mean Difference
(SD)
t
df
pvalue
Cohen's d
0.1 (0.6)
0.6 (1.1)
0.5 (1.1)
-0.4 (1.0)
-0.1 (0.7)
0.1 (0.7)
0.1 (1.0)
0.1 (1.0)
-0.2 (0.7)
-0.0 (0.6)
0.0 (1.0)
0.5 (1.8)
0.4 (1.9)
-0.2 (1.3)
-0.0 (1.0)
0.3
2.3
1.7
-0.9
-0.0
70
70
70
47
69
0.75
0.02
0.09
0.38
0.97
0.0
0.5
0.4
0.2
0.2
Total
-0.9 (2.5)
-0.6 (3.4)
-1.8 (4.5)
-3.4 (8.0)
0.3 (2.8)
-0.2 (3.2)
0.2 (4.7)
0.2 (8.0)
-1.2 (4.3)
-0.4 (5.4)
-2.0 (7.4)
-3.6 (13.1)
-2.3
-0.7
-2.3
-2.3
70
70
70
70
0.03
0.49
0.03
0.02
0.5
0.1
0.4
0.5
Depression
-1.8 (7.3)
0.8 (10.7)
-2.6 (15.1)
-1.4
69
0.16
0.3
-0.7 (11.1)
-1.8 (14.5)
7.1 (23.3)
-4.4 (20.3)
0.50
-1.0
2.5
-1.8
69
69
68
65
0.62
0.30
0.01
0.09
0.1
0.2
0.5
0.4
Measure
Cognitive Tests
WAIS-LNS
WMS-LM I
WMS-LM II
TMT-A
COWAT
Symptom Tests
PANSS
Positive
Negative
General
DASS
Anxiety
Stress
SF-36v2 Total
SQLS Total
-1.3 (6.2)
-1.6 (8.2)
4.3 (12.6)
-4.0 (11.8)
-0.6 (7.2)
0.2 (9.5)
-2.8 (15.3)
0.4 (12.3)
Cohen's d calculated as Mean Diff/ SD pooled
cognitive measures are z-score adjusted
WAIS-LNS Wechsler Adult Intelligence scale Letter Number Sequencing,WMS- LM I Wechsler Memory Scale Logical Memory I,WMS-LM II Wechsler Memory Scale
Logical Memory II, TMT-A trail making test A, COWAT Controlled Oral Word Association Test, PANSS Positive and Negative Syndrome Scale, DASS Depression
Anxiety and Stress Scale, SF-36v2 Short Form 36 Version 2 Health Survey Questionnaire, SQLS Schizophrenia Quality of Life Scale
4
Supplemental Table 5. Carryover effects
Supplemental Table 5
Measure
WAIS-LNS
WMSR-LM I
WMSR-LM II
COWAT
TMT-A
PANSS positive
PANSS negative
PANSS general
PANSS Total
DASS depression
DASS anxiety
DASS stress
SF-36v2 Total
SQLS Total
Mean Diff (SE)
p-value
-0.2 (0.2)
0.26
-0.9 (0.2)
<0.01***
-0.9 (0.2)
<0.01***
-0.2 (0.2)
0.29
0.8 (0.3)
<0.01
-0.9 (0.7)
0.18
0.6 (0.9)
0.49
0.4 (1.3)
0.75
0.1 (2.2)
0.96
-0.7 (2.5)
0.77
0.3 (1.8)
0.88
-4.3 (2.4)
0.08
5.8 (4.5)
0.21
-0.3 (3.2)
0.93
***p<0.001
Carryover calculated as placebo/raloxifene versus raloxifene placebo
on (period 1 change score +period 2 change score)
WAIS-LNS Wechsler Adult Intelligence scale Letter Number
Sequencing, WMSR-LM I Wechsler Memory Scale Revised Logical
Memory I, WMSR- LM II Wechsler Memory Scale Revised Logical
Memory II, TMT-A trail making test A, COWAT Controlled Oral Word
Association Test, PANSS Positive and Negative Syndrome Scale, DASS
Depression Anxiety and Stress Scale, SF-36v2 Short Form 36 Version 2
Health Survey Questionnaire, SQLS Schizophrenia Quality of Life Scale.
5
Supplemental Table 6. Mixed (M)ANOVAs with sex and condition as between group factors
Supplemental Table 6
Mixed (M)ANOVA OUTCOMES
Mixed MANOVA: LMI, LMII, LNS, COWAT
Between Subjects
Condition
Sex
Condition*Sex
Within Subjects
Time
Time *Condition
Time * Sex
Time * Condition * Sex
Mixed ANOVA: TMT-A
Time
Time * Condition
Time * Sex
Time * Condition * Sex
UNIVARIATE OUTCOMES
Interaction
Measure
Univariate Analysis: LMI, LMII, LNS, COWAT
Time * Condition
LMI
LMII
LNS
COWAT
Time * Condition * Sex
LMI
LMII
LNS
COWAT
W-L Value (hyp df, err
df)=F
p-value
1.0 F(4,72)=0.4
0.9 F(4,72)=1.0
1.0 F(4,72)=0.6
0.8 F(4,72)=4.8
0.8 F(4,72)=4.1
0.9 F(4,72)=1.0
0.8 F(4,72)=4.3
0.841
0.398
0.644
0.002
0.005
0.434
0.004
0.9 F(1,53)=6.2
0.9 F(1,53)=6.7
1.0 F(1,53)=2.4
1.0 F(1,53)=0.0
0.016
0.012
0.126
0.838
H-F Value (hyp df, err
df)=F
p-value
2.9 F(1,75)=5.5
1.1 F(1,75)=1.7
0.2 F(1,75)=1.2
1.7 F(1,75)=8.2
0.8 F(1,75)=1.6
0.1 F(1,75)=0.1
2.9 F(1,75)=5.5
2.9 F(1,75)=5.5
0.021
0.202
0.271
0.005
0.209
0.768
0.639
0.002
Two separate mixed (M)ANOVAS, one with z-transformed measures of LMI (Weschler Logical
Memory I), LMII (Weschler Logical Memory II), LNS (WAIS-III Letter-Number-Sequencing), and COWAT
(Controlled Oral Word Association Test), and the second repeated measure ANOVA with ztransformed TMT-A (Trail Making Test A). Both repeated measure (M) ANOVAS included condition
(placebo v. raloxifene) and sex (male v. female) as between subject measures and time (baseline visit
v. 6-week visit) as the within subject factor. Reported above are the multivariate outcomes for the
separate (M)ANOVAS and univariate results for the MANOVA with LMI, LMII, LNS, and COWAT. W-L
Value refers to Wilks' Lamda and H-F refers to Huynh-Feldt values. Negative mean differences of LMI,
LMII, LNS, and COWAT and a positive mean difference of TMT-A indicate an improvement.
6
Supplemental Table 7. Lease significant difference pairwise comparisons for mixed
(M)ANOVAs with sex and condition as between group factors
Supplemental Table 7
placebo
pMeasure Sex
Mean Difference (SE)
value
Time*Condition Pairwise Comparisons
LMI
-0.2 (0.2)
0.240
LMII
-0.4 (0.2)
0.074
LNS
-0.2 (0.1)
0.087
COWAT
0.3 (0.1)
0.019
TMT-A
-0.0 (0.2)
0.952
Time*Condition*Sex Pairwise Comparisons
LMI
male
-0.4 (0.2)
0.027
female
0.0 (0.3)
0.934
LMII
male
-0.3 (0.2)
0.200
female
-0.4 (0.3)
0.192
LNS
male
-0.3 (0.1)
0.032
female
-0.1 (0.2)
0.534
COWAT male
0.1 (0.1)
0.562
female
0.5 (0.2)
0.015
TMT-A
male
0.2 (0.2)
0.340
female
-0.3 (0.3)
0.432
raloxifene
Mean Difference
(SE)
p-value
-0.8 (0.2)
-0.7 (0.2)
-0.0 (0.1)
-0.2 (0.1)
0.7 (0.2)
p<0.001
p<0.001
0.803
0.109
0.001
-0.7 (0.2)
-0.8 (0.2)
-0.7 (0.2)
-0.7 (0.3)
0.0 (0.1)
0.0 (0.1)
0.1 (0.1)
-0.5 (0.2)
0.9 (0.2)
0.5 (0.3)
0.002
0.001
0.005
0.011
0.818
0.898
0.382
0.004
0.001
0.073
Results of Least Significant Difference Pairwise comparisons for Time (baseline v. 6week visit) by Condition (raloxifene v. placebo) interaction and Time by condition by
sex (male v. female) interaction for the two separate mixed (M)ANOVAS represented
in supplemental table 6. Measures refer to LMI (Weschler Logical Memory I), LMII
(Weschler Logical Memory II), LNS (WAIS-III Letter-Number-Sequencing), COWAT
(Controlled Oral Word Association Test), and TMT-A (Trail Making Test A). Negative
mean differences of LMI, LMII, LNS, and COWAT and a positive mean difference of
TMT-A indicate an improvement.
7
Supplemental Table 8. Cognitive responders
Supplemental Table 8
Characteristics
Cognitive Tests
WAIS-LNS
WMSR-LM I
WMSR-LM II
TMT-A
COWAT
Total Unique Individuals
Chi-square
Number Needed to Treat
Raloxifene first
Placebo first
n = 40
n=39
1
12
12
1
1
0
4
5
0
0
6 (15%)
16 (40%)
5.6 p=0.02
4
WAIS-LNS Wechsler Adult Intelligence scale Letter Number Sequencing,
WMSR-LM I Wechsler Memory Scale Revised Logical Memory I, WMSR-LM II
Wechsler Memory Scale Revised Logical Memory II, COWAT Controlled Oral
Word Association Test, TMT-A Trail Making Test A.
8
Supplemental Table 9. Symptom responders
Supplemental Table 9
No improvement Improvement Chi-square (df) p-value
raloxifene
34
6
PANSS positive
1.4 (1) p=0.24
placebo
29
10
raloxifene
31
9
PANSS negative
0.3 (1) p=0.61
placebo
32
7
raloxifene
33
7
PANSS general
0.0 (1) p=0.96
placebo
32
7
raloxifene
35
5
PANSS total
0.1 (1) p=0.71
placebo
33
6
raloxifene
21
18
DAS depression
2.7 (1) p=0.10
placebo
28
11
raloxifene
22
17
DAS anxiety
0.9 (1) p=0.35
placebo
26
13
raloxifene
21
18
DAS stress
0.8 (1) p=0.36
placebo
25
14
raloxifene
34
5
SF-36v2 total
0.1 (1) p=0.71
placebo
32
6
raloxifene
23
15
SQLS total
0.2 (1) p=0.70
placebo
24
13
Raloxifene
31 (78%)
Total Improved
Placebo
30 (77%)
Chi-square
0.0 (1) p=0.95
Number Needed to Treat
173
% change calculated as (week 6 minus baseline)/(baseline)
PANSS Positive and Negative Syndrome Scale, DASS Depression Anxiety and Stress Scale, SF36v2 Short Form 36 Version 2 Health Survey Questionnaire, SQLS Schizophrenia Quality of
Life Scale.
Improvement defined as ≥ 20% symptom severity reduction. No improvement defined as
<20% symptom severity reduction.
9
Supplemental Table 10. Cognitive and symptom outcomes in crossover analysis
Supplemental Table 10
Measure
Cognitive Outcomes
Cognitive Tests X Treatment
TMT-A X Treatment
Symptom Outcomes
PANSS X Treatment
N
Wilk’s Lambda
F test
p-value
70
48
0.9
0.9
(4,66)=1.8
(1,47)=4.3
0.14
0.04
71
(3,68)=1.3
0.28
DASS X Treatment
70
0.9
1.0
(3,67)=0.7
0.57
SF-36v2 X Treatment
69
1.0
(1,68)=0.0
0.88
SQLS X Treatment
66
1.0
(1,65)=0.8
0.37
Cognitive z-scores were used for cognitive analyses
Cognitive Tests (Wechsler Adult Intelligence Scale Letter Number Sequencing, Wechsler
Memory Scale Revised Logical Memory I, Wechsler Memory Scale Revised Logical Memory II,
COWAT Controlled Oral Word Association Test), Treatment (raloxifene versus placebo), Time
(1=baseline, 2=week 6), TMT-A (Trail Making Test A), PANSS (Positive and Negative Syndrome
Scale [incl. positive, negative, and general subtests]), DASS (Depression Anxiety and Stress
Scale), SF-36v2 (short form 36 version 2 health survey questionnaire, SQLS (Schizophrenia
Quality of Life Scale
Crossover Analysis and Results
To assess the overall crossover design results, difference scores were calculated for each
outcome measure for each phase (period 1: week 6 score minus baseline score, period 2:
week 13 score minus week 6 score). These difference scores were combined for the
raloxifene and placebo conditions, regardless of period. Treatment effects on cognition
were analysed using a repeated measures MANOVA (with LNS, LM I, LM II, and
COWAT as dependent variables) and a repeated measures ANOVA (with TMT-A as a
dependent variable) with treatment condition (raloxifene versus placebo) as the within
subjects measure. Treatment effects for symptom, emotional and functional measures
were analysed using separate repeated measures MANOVAs (for PANSS and DASS)
and repeated measures ANOVAs (for SF36-v2 and SQLS) with treatment condition
(raloxifene versus placebo) as the within subjects factor.
Treatment effects for the full 13-week crossover trial design revealed a significant
treatment effect only on TMT-A, Wilk’s Lambda 0.9, (1, 47) = 4.3, p = 0.04, where the
raloxifene condition showed a significant benefit, mean difference (SD) = -0.5, (1.0),
relative to placebo, mean difference (SD) = -0.1, (0.7), (see table above). The crossover
design analysis did not show any other significant effects of raloxifene in relation to
cognitive, symptom, emotional, or functional measures.
10
Supplemental Figure 1. Example of Carryover Effect on Logical Memory I (LM I)
Figure 1. A carryover effect is evident in the raloxifene/placebo (R/P) condition,
where during the placebo treatment condition in phase II the group that was
previously administered raloxifene does not return to their baseline. Wechsler
Memory Scale Revised Logical Memory I is a measure of immediate verbal memory.
WO = washout period.
11