Assessing competence to complete psychiatric advance directives with the competence assessment tool for psychiatric advance directives

The Competence Assessment Tool for Psychiatric Advance Directives (CAT-PAD), a new instrument designed to assess competence to complete a psychiatric advance directive (PAD), is described. Initial psychometric properties and data regarding participant performance on the instrument are detailed. Study participants were 80 outpatients with at least two psychiatric crises in the previous 2 years. The CAT-PAD has three scales that assess decisional capacities regarding the nature and value of PADs and a specific treatment choice: Understanding, Appreciation, and Reasoning. Construct and discriminant validity were evaluated using the AD-Maker competence questions, symptom and functioning scales, and clinical and demographic characteristics. Reliability was strong for the Understanding and Reasoning scales and total score, and adequate for the Appreciation scale. Construct validity was demonstrated in relation to the AD-Maker competence questions and scales assessing psychotic symptoms. The CAT-PAD was generally unbiased with respect to gender, ethnicity, and age. Controlling for psychotic symptoms, diagnosis was not significantly related to CAT-PAD scores. Most participants performed well on the CAT-PAD. Using rigid cutoffs for the CAT-PAD is not advised due to lack of consensus on the degree of capacities required for completing a PAD, and differences in situational demands. Routine screening using the CAT-PAD is also not recommended, but rather assessment is suggested when a priori doubts exist about a person's decisional capacity. Such use of the CAT-PAD may allow clinicians to better trust the content of PADs, which may, in turn, increase the likelihood PADs will be honored.     

Psychiatric advance directives among public mental health consumers in five U.S. cities: prevalence, demand, and correlates

Psychiatric advance directives (PADs) are legal instruments that allow competent persons to document their preferences regarding future mental health treatment and to designate a surrogate decisionmaker in the event they lose capacity to make reliable treatment decisions during an acute episode of psychiatric illness. This study reports the findings of a survey of 1,011 psychiatric outpatients in five U.S. cities about their interest in, and completion of, PADs. Across the sites, only 4 to 13 percent of participants had completed a PAD; however, between 66 and 77 percent reported wanting to complete one if given assistance. Significantly higher demand for PADs was found among participants who were female; were nonwhite; had a history of self-harm, arrest, and decreased personal autonomy; and those who felt pressured to take medication. Actual completion of PADs was more likely among participants with higher insight, those reporting leverage by a representative payee, and those who felt external pressure to keep outpatient appointments for mental health treatment.     

Understanding the personal and clinical utility of psychiatric advance directives: a qualitative perspective

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self-determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty-eight open-ended, semi-structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self-determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PAD to clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient-provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients.     

Reducing Barriers to Completing Psychiatric Advance Directives

Objective Psychiatric advance directives (PADs) allow individuals to plan for future mental health treatment. However, little is known about barriers to PAD completion. This paper examines an intervention’s effect in reducing barriers to PAD completion. Method Patients were randomly assigned to a facilitated PAD session or control group. Barriers associated with (1) the PAD documents and (2) external support for PADs were assessed at baseline (n = 462), 6 months (n = 380) and 1 year (n = 362). Results There were no significant baseline between-group differences on the two barriers. However, at follow-up both barriers were significantly lower in the experimental group. Further, barriers were predictive of PAD completion. Conclusions Structured facilitation can significantly reduce barriers to PAD completion. However, the intervention did not eliminate barriers. Findings are discussed in the context of possible system-level changes to further reduce barriers to PAD completion.     

Consumer, Provider, and Informal Caregiver Opinions on Psychiatric Advance Directives

Psychiatric advance directives (PADs) are legal documents that permit competent adults to make choices in the present about their future psychiatric treatment if they lose their decision-making capacity. PADs may provide for the appointment of surrogate decision-makers. The present project was undertaken to obtain opinions from the consumer (the patient), provider, and informal caregiver/surrogate about the Oregon PAD. Results of this pilot study show that the majority of no-PAD group consumers reported that they did not get enough help with PAD preparation. The PAD group consumers reported feeling empowered by PAD preparation, but at the follow-up interview, they were less enthusiastic and more critical of PAD policy that was relevant to implementation. Many providers also were concerned about successful PAD implementation. PAD legislation alone does not translate into adequate policy.     

The Rôle of Sex in Modern Society

Abstract

Psychiatric advance directives (PADs) are legal tools that allow competent individuals to declare preferences for future mental health treatment when they may not be capable of doing so as a result of a psychiatric crisis. PADs allow individuals to maintain self–determination during times when they are most vulnerable to loss of autonomy and in need of assistance to make their preferences known and honored. This article describes the content of twenty–eight open–ended, semi–structured qualitative interviews of adults with PADs who have experienced psychiatric crises. The qualitative analysis revealed three major themes from the interviews: (1) PADs as tools for empowerment and self–determination, (2) limited knowledge of PADs among service providers; and (3) difficulties communicating PADs to inpatient staff. In general, many participants expressed enthusiasm of the implementation of PADs but concern regarding clinicians' general lack of awareness about them. Additionally, some consumers discussed discomfort in even mentioning that they had a PADto clinicians for fear of a negative response from them, or some type of involuntary treatment during their hospitalization. However, participants consistently viewed PADs as a positive tool to promote autonomy with the potential to facilitate stronger patient–provider relationships. Therefore, when working with individuals in psychiatric crisis who have a PAD, and who have never before experienced a sense of control over their own treatment, clinicians must recognize the potential troubling disequilibrium this sense of control may engender. In sum, though the most significant challenges facing the implementation of PADs involve clinicians' familiarity with and education about PADs, much promise for the future growth of PADs lies in the benefits perceived by the patients.     

Primary afterdischarge in organotypic hippocampal slice cultures: Effects of standard antiepileptic drugs

Purpose: In the hippocampus intense high frequency electrical stimulation induces a long‐lasting rhythmic synchronization (primary afterdischarge). In order to examine the suitability of primary afterdischarges (PADs) in organotypic hippocampal slice cultures (OHSCs) as an in vitro model of evoked seizures, we have worked out in detail the sensitivity of PADs to standard antiepileptic drugs (AEDs) and compared the necessary concentrations to those that were effective in animal models of partial and generalized tonic–clonic seizures. Methods: OHSCs were prepared according to the interface culture method from 8 to 11‐day‐old Wistar rats. A PAD in CA1 was elicited by stimulating the stratum radiatum with an intensity of two times that required to elicit a maximal population spike. The effects of carbamazepine, phenytoin, valproic acid, phenobarbital, diazepam, and ethosuximide on the duration and on frequency properties of PADs and the tonic‐like and clonic‐like subdivisions of PADs were determined, and as a measure of the AEDs potency half maximal effective concentration (EC₅₀) values were calculated from concentration–response curves. Key Finding: Carbamazepine, phenytoin, valproic acid, phenobarbital, and diazepam reduced the durations of PADs and tonic‐like and clonic‐like subdivisions of PADs. The effects were concentration dependent and reversible. Ethosuximide was ineffective. The effects on subdivisions of PADs differed between AEDs. Carbamazepine and phenytoin shortened the tonic‐like and clonic‐like subdivisions at similar proportions, whereas phenobarbital, diazepam, and valproic acid preferentially shortened the clonic‐like subdivision. Diazepam at low concentrations increased the duration of tonic‐like subdivisions, an effect not seen with the other AEDs. The suppressive effects of AEDs on frequency properties of tonic‐like and clonic‐like subdivisions were variable and observed only at higher concentrations. Significance: Carbamazepine and phenytoin were more effective in the PAD test in OHSCs than in the maximal electroshock and kindled seizures tests. The effectiveness of phenobarbital, diazepam, and valproic acid in the PAD test matched their effectiveness in the MES test and—with the exception of valproic acid and diazepam—in kindled seizures tests. Valproic acid was less effective in OHSCs than in the kindled seizure tests, and diazepam was more (generalized seizures) or less (focal seizures and afterdischarge durations) effective in this animal model than in OHSCs. We conclude that the PAD test in OHSCs is a suitable in vitro model of evoked seizures. The model could serve as an initial screen to identify the most promising leads for further evaluation and characterization in in vivo models of efficacy and toxicity.     

Psychiatric advance directives: a tool for consumer empowerment and recovery

Individuals with psychiatric disabilities identify choice and self-direction as central elements of recovery. During times of psychiatric crisis people may experience a frightening loss of choice and self-direction, which can be damaging and traumatic. Psychiatric advance directives (PADs) are legal documents created to address this loss of autonomy and choice during crises by allowing individuals to communicate in the present wishes for care during a future crisis. This paper examines the ways in which PADs support and can be a tool for recovery and discusses future recovery-oriented directions for PAD research and intervention.     

Neuroscience meets behavior: A systematic literature review on magnetic resonance imaging of the brain combined with real-world digital phenotyping

A primary goal of neuroscience is to understand the relationship between the brain and behavior. While magnetic resonance imaging (MRI) examines brain structure and function under controlled conditions, digital phenotyping via portable automatic devices (PAD) quantifies behavior in real-world settings. Combining these two technologies may bridge the gap between brain imaging, physiology, and real-time behavior, enhancing the generalizability of laboratory and clinical findings. However, the use of MRI and data from PADs outside the MRI scanner remains underexplored. Herein, we present a Preferred Reporting Items for Systematic Reviews and Meta-Analysis systematic literature review that identifies and analyzes the current state of research on the integration of brain MRI and PADs. PubMed and Scopus were automatically searched using keywords covering various MRI techniques and PADs. Abstracts were screened to only include articles that collected MRI brain data and PAD data outside the laboratory environment. Full-text screening was then conducted to ensure included articles combined quantitative data from MRI with data from PADs, yielding 94 selected papers for a total of N = 14,778 subjects. Results were reported as cross-frequency tables between brain imaging and behavior sampling methods and patterns were identified through network analysis. Furthermore, brain maps reported in the studies were synthesized according to the measurement modalities that were used. Results demonstrate the feasibility of integrating MRI and PADs across various study designs, patient and control populations, and age groups. The majority of published literature combines functional, T1-weighted, and diffusion weighted MRI with physical activity sensors, ecological momentary assessment via PADs, and sleep. The literature further highlights specific brain regions frequently correlated with distinct MRI-PAD combinations. These combinations enable in-depth studies on how physiology, brain function and behavior influence each other. Our review highlights the potential for constructing brain–behavior models that extend beyond the scanner and into real-world contexts.     

A Review of Barriers to Using Psychiatric Advance Directives in Clinical Practice

Despite advocacy and demand for psychiatric advance directives (PADs), uptake and implementation in clinical practice is low. We examine why PAD implementation has been difficult globally by reviewing barriers in existing evidence. The review includes 30 studies, and identified 13 barriers, clustered into system level barriers, health professional level barriers, and service user level barriers. The considerable barriers to uptake and implementation hamper PAD use. We propose several potential strategies for overcoming some of the barriers. In order to realise these strategies, additional research is needed, particularly more field-based and operational research to understand processes and difficulties experienced in clinical practice.     

Superseding psychiatric advance directives: ethical and legal considerations

Psychiatric advance directives (PADs) were introduced in the 1980s as legal instruments for psychiatric patients to retain some choice over their own mental health treatment during periods of decisional incapacity. However, PADs are nested in larger structures of mental health law and policy that protect the interests of parties other than the patient, and which, in situations of conflict involving the treatment of incapacitated patients, tend to favor the clinician's professional judgment over the patient's manifest wishes to avoid standard treatment. Thus, PADs are trumped by civil commitment law and may also be legally overridden by clinicians who, acting in good faith, consider PAD instructions to be inconsistent with accepted clinical standards of care. We discuss philosophical-ethical and legal issues surrounding overriding PADs and offer analysis of the possible future of legal cases in which the question of overriding PADs and fiscal concerns may collide.     

Developmental and age‐related changes of peptidylarginine deiminase 2 in the mouse brain

Peptidylarginine deiminases (PADs) are a group of posttranslational modification enzymes that citrullinate (deiminate) protein arginine residues in a Ca²⁺‐dependent manner. Enzymatic citrullination abolishes positive charges of native protein molecules, inevitably causing significant alterations in their structure and functions. Among the five isoforms of PADs, PAD2 and PAD4 are proved occupants of the central nervous system (CNS), and especially PAD2 is a main PAD enzyme expressed in the CNS. We previously reported that abnormal protein citrullination by PAD2 has been closely associated with the pathogenesis of neurodegenerative disorders such as Alzheimer's disease and prion disease. Protein citrullination in these patients is thought to play a role during the initiation and/or progression of disease. However, the contribution of changes in PAD2 levels, and consequent citrullination, during developmental and aging processes remained unclear. Therefore, we used quantitative real‐time RT‐PCR, Western blot analysis, and immunohistochemical methods to measure PAD2 expression and localization in the brain during those processes. PAD2 mRNA expression was detected in the brains of mice as early as embryonic day 15, and its expression in cerebral cortex, hippocampus, and cerebellum increased significantly as the animals aged from 3 to 30 months old. No citrullinated proteins were detected during that period. Moreover, we found here, for the first time, that PAD2 localized specifically in the neuronal cells of the cerebral cortex and Purkinje cells of the cerebellum. These findings indicate that, despite PAD2's normally inactive status, it becomes active and citrullinates cellular proteins, but only when the intracellular Ca²⁺ balance is upset during neurodegenerative changes. © 2009 Wiley‐Liss, Inc.     

Clinically relevant depressive symptoms and peripheral arterial disease in elderly men and women. Results from a large cohort study in Southern China

OBJECTIVE: Results from previous epidemiological studies on the relationship between depression and peripheral arterial diseases (PADs) were mixed. Therefore, a study was conducted to investigate this relationship in a large Chinese elderly sample. METHODS: Cross-sectional data from the baseline examination of a large cohort study on Chinese elderly were used in this current study. A stratified convenience sample of 3985 Hong Kong men and women aged 65 to 92 were recruited from the community. Clinically relevant depressive symptoms were assessed by the use of a validated screening instrument for depression: the Chinese version of the Short Form of Geriatric Depression Scale. PAD was assessed by the ankle-brachial index, with an index of <0.9 indicating the presence of PAD. Multiple logistic regression was used to compare the presence of PAD in depressed and nondepressed subjects, controlling for confounding variables for the relationship. RESULTS: In the total subject population, more severe peripheral atherosclerosis was associated with a higher prevalence of depressive disorders. The presence of peripheral atherosclerosis was associated with an adjusted odds ratio of 1.46 (95% confidence interval=1.01-2.10) of having clinically relevant depressive symptoms. CONCLUSION: We showed that depressive symptoms were associated with peripheral atherosclerosis in the Asian elderly after adjusting for stroke and cardiovascular diseases. Prospective studies are needed to provide conclusive evidence on the causality of the relationship between peripheral atherosclerosis and depressive symptoms.     

Commentary: psychiatric advance directives at a crossroads--when can PADs be overridden?

Current statutes enabling psychiatric advance directives (PADs) typically include provisions allowing override of patients' choices by treatment staff. Lest the purpose of the PAD be vitiated by too broad an application of the override mechanism, its use should be carefully limited. In inpatient settings, voluntary patients should have the right to decline treatments in advance, although not an absolute right to demand treatments of their choosing. The situation of involuntary patients is more complex. Permitting PADs to trump commitment statutes would undercut the combined parens patriae/police power rationale for commitment, a path taken currently by no U.S. jurisdiction. Moreover, PADs should not be permitted to negate the usual mechanisms for involuntary treatment of committed patients; to do otherwise risks forcing facilities to confine indefinitely persons they cannot treat. Even in those circumstances, however, where PADs provide evidence of reasonable patient preferences (e.g., for one medication over another), the choices they embody should be respected.     

Induction of peptidylarginine deiminase 2 and 3 by dibutyryl cAMP via cAMP‐PKA signaling in human astrocytoma U‐251MG cells

Peptidylarginine deiminases (PADs) are posttranslational modification enzymes that citrullinate (deiminate) protein arginine residues in a calcium‐dependent manner, yielding citrulline residues. Enzymatic citrullination abolishes positive charges of native protein molecules, inevitably causing significant alterations in their structure and function. Previously, we reported the abnormal accumulation of citrullinated proteins and an increase of PAD2 content in hippocampi of patients with Alzheimer disease. In this study, we investigated PAD expression by using dibutyryl cAMP (dbcAMP) in human astrocytoma U‐251MG cells. Under normal culture conditions, PAD2 and PAD3 mRNA expression is detectable with quantitative PCR in U‐251MG cells. The addition of dbcAMP in a dose‐dependent manner significantly increased this mRNA expression and protein levels. Moreover, PAD enzyme activity also increased significantly and dose‐dependently. Furthermore, the expression of PAD2 and PAD3 mRNA was inhibited by the cAMP‐dependent PKA inhibitor KT5720, suggesting that such expression of dbcAMP‐induced PAD2 and PAD3 mRNA is mediated by the cAMP‐PKA signaling pathway in U‐251MG cells. This is the first report to document the PAD2 and PAD3 mRNA expression induced by dbcAMP and to attribute the induction of these genes to mediation by the cAMP‐PKA signaling pathway in U‐251MG cells. © 2016 Wiley Periodicals, Inc.     

Abnormal accumulation of citrullinated proteins catalyzed by peptidylarginine deiminase in hippocampal extracts from patients with Alzheimer's disease

Citrullinated proteins are the products of a posttranslational process in which arginine residues undergo modification into citrulline residues when catalyzed by peptidylarginine deiminases (PADs) in a calcium ion-dependent manner. In our previous report, PAD2 expressed mainly in the rat cerebrum became activated early in the neurodegenerative process. To elucidate the involvement of protein citrullination in human neuronal degeneration, we examined whether citrullinated proteins are produced during Alzheimer's disease (AD). By Western blot analysis with antimodified citrulline antibody, citrullinated proteins of varied molecular weights were detected in hippocampal tissues from patients with AD but not normal humans. Two of the citrullinated proteins were identified as vimentin and glial fibrillary acidic protein (GFAP) by using two-dimensional gel electrophoresis and MALDI-TOF mass spectrometry. Interestingly, PAD2 was detected in hippocampal extracts from AD and normal brains, but the amount of PAD2 in the AD tissue was markedly greater. Histochemical analysis revealed citrullinated proteins throughout the hippocampus, especially in the dentate gyrus and stratum radiatum of CA1 and CA2 areas. However, no citrullinated proteins were detected in the normal hippocampus. PAD2 immunoreactivity was also ubiquitous throughout both the AD and the normal hippocampal areas. PAD2 enrichment coincided well with citrullinated protein positivity. Double immunofluorescence staining revealed that citrullinated protein- and PAD2-positive cells also coincided with GFAP-positive cells, but not all GFAP-positive cells were positive for PAD2. As with GFAP, which is an astrocyte-specific marker protein, PAD2 is distributed mainly in astrocytes. These collective results, the abnormal accumulation of citrullinated proteins and abnormal activation of PAD2 in hippocampi of patients with AD, strongly suggest that PAD has an important role in the onset and progression of AD and that citrullinated proteins may become a useful marker for human neurodegenerative diseases.     

Peripheral arterial disease in older people with intellectual disability in The Netherlands using the ankle-brachial index: Results of the HA-ID study

Older people with an intellectual disability (ID) have been shown to have similar to increased cardiovascular risks as compared to the general population. Peripheral arterial disease (PAD), atherosclerosis distal from the aortic bifurcation, is associated with increased cardiovascular morbidity and mortality. The prevalence of PAD has not been investigated in this population. Therefore, the aim of the present study was to determine the prevalence of PAD in older people with ID in The Netherlands, the rate of prior diagnoses, and correlations with participant characteristics, and to compare the prevalence with PAD in the general Dutch population. 771 people aged 50 years and over participated in ankle-brachial index (ABI) measurement as part of a multi-centre cross-sectional study (HA-ID study). PAD was defined as an ABI < 0.9. After excluding those, who met the exclusion criteria, 629 participants remained. PAD was present in 20.7% of the participants and 97% had not been diagnosed before. People with higher age, smokers and people who lived in central settings, walked with support and were more dependent in activities of daily living were more at risk of PAD. Prevalence of PAD is higher than in the general population (17.4% of 562 eligible participants with ID, as compared to 8.1% of 917 Dutch participants of the PANDORA study, a pan-European study into the prevalence of PAD) through all age groups. Because the high prevalence of PAD implies a serious health risk for older people with ID, we recommend that ankle-brachial index measurement is to be routinely performed as part of the cardiovascular risk management in this group.     

Involvement of peptidylarginine deiminase-mediated post-translational citrullination in pathogenesis of sporadic Creutzfeldt-Jakob disease

Peptidylarginine deiminases (PADs)-mediated post-translational citrullination processes play key roles in protein functions and structural stability through the conversion of arginine to citrulline in the presence of excessive calcium concentrations. In brain, PAD2 is abundantly expressed and can be involved in citrullination in disease. Recently, we have reported pathological characterization of PAD2 and citrullinated proteins in scrapie-infected mice, but the implication of protein citrullination in the pathophysiology in human prion disease is not clear. In the present study, we explored the molecular and biological involvement of PAD2 and the pathogenesis of citrullinated proteins in frontal cortex of patients with sporadic Creutzfeldt-Jakob disease (sCJD). We found increased expression of PAD2 in reactive astrocytes that also contained increased levels of citrullinated proteins. In addition, PAD activity was significantly elevated in patients with sCJD compared to controls. From two-dimensional gel electrophoresis and MALDI-TOF mass analysis, we found various citrullinated candidates, including cytoskeletal and energy metabolism-associated proteins such as vimentin, glial fibrillary acidic protein, enolase, and phosphoglycerate kinase. Based on these findings, our investigations suggest that PAD2 activation and aberrant citrullinated proteins could play a role in pathogenesis and have value as a marker for the postmortem classification of neurodegenerative diseases.     

酒依赖患者急性脱瘾治疗后大脑皮质厚度的磁共振成像研究

目的:探索急性脱瘾治疗后酒依赖患者脑区皮质厚度的异常特征及与酒依赖临床特征的关联。方法:以2017年4月至2018年4月的住院男性酒依赖患者（患者组, n=33）与年龄、受教育程度匹配的健康对照（对照组, n=35）为研究对象,收集大脑皮质功能磁共振的影像学数据和患者一般人口学及临床资料;使用F...     

Mass spectrometric identification of citrullination sites and immunohistochemical detection of citrullinated glial fibrillary acidic protein in Alzheimer's disease brains

Peptidylarginine deiminases (PADs) are posttranslational modification enzymes that convert protein arginine to citrulline residues in a calcium ion‐dependent manner. Previously, we reported the abnormal accumulation of citrullinated proteins and the increase in the amount of PAD2 in hippocampi from Alzheimer's disease (AD) patients. Moreover, glial fibrillary acidic protein (GFAP), an astrocyte‐specific marker protein, and vimentin were identified as citrullinated proteins by using two‐dimensional gel electrophoresis and MALDI‐TOF mass spectrometry. To clarify the substrate specificity of PADs against GFAP, we prepared recombinant human (rh)PAD1, rhPAD2, rhPAD3, rhPAD4, and rhGFAP. After incubation of rhGFAP with rhPAD1, rhPAD2, rhPAD3, and rhPAD4, citrullinated (cit‐)rhGFAP was detected by Western blotting. The citrullination of rhGFAP by rhPAD2 was unique, specific, and time dependent; additionally, rhPAD1 slightly citrullinated rhGFAP. We then generated eight anti‐cit‐rhGFAP monoclonal antibodies, CTGF‐125, ?128, ?129, ?1212, ?1213, ?1221, ?122R, and ?1224R, which reacted specifically with cit‐rhGFAP. Two of those eight monoclonal antibodies, CTGF‐122R and ?1224R, reacted with both cit‐rhGFAP and rhGFAP in Western blots. By using the CTGF‐1221 antibody and a tandem mass spectrometer, we identified the two independent citrullination sites (R270Cit and R416Cit) of cit‐rhGFAP. Immunohistochemical analysis with CTGF‐1221 antibody revealed cit‐GFAP staining in the hippocampus of AD brain, and the cit‐GFAP‐positive cells appeared to be astrocyte‐like cells. These collective results strongly suggest that PAD2 is responsible for the citrullination of GFAP in the progression of AD and that the monoclonal antibody CTGF‐1221, reacting with cit‐GFAP at R270Cit and R416Cit, is useful for immunohistochemical investigation of AD brains. © 2015 Wiley Periodicals, Inc.