What do we really know about late-onset schizophrenia?

Estrogen and psychosis - a review and future directions

The link between sex hormones and schizophrenia has been suspected for over a century; however, scientific evidence supporting the pharmacotherapeutic effects of exogenous estrogen has only started to emerge during the past three decades. Accumulating evidence from epidemiological and basic research suggests that estrogen has a protective effect in women vulnerable to schizophrenia. Such evidence has led multiple researchers to investigate the role of estrogen in schizophrenia and its use in treatment. This narrative review provides an overview of the effects of estrogen as well as summarizes the recent work regarding estrogen as a treatment for schizophrenia, particularly the use of new-generation selective estrogen receptor modulators.

Gender differences in first episode psychosis: Some arguments to develop gender specific treatment strategies

INTRODUCTION

Some aspects of gender differences in patients with schizophrenia spectrum disorders (SSD) have been studied, especially in cross-sectional designs and with a short-term follow-up. However, only a few studies have considered the evolution during the follow-up of SSD patients according to their gender. In this study, we explore gender differences from the time of entry in an early intervention program for psychosis, up to three years follow-up.

METHODS

We conducted a prospective study including a cohort of 474 patients treated at the Treatment and Early Intervention in Psychosis (TIPP) program, 319 men and 155 women, having presented a first episode of psychosis (FEP). Data regarding premorbid and baseline sociodemographic, psychopathological and patient functioning, were collected. These data were reassessed longitudinally after 2, 6, 12, 18, 24, 30 and 36 months after entry in TIPP.

RESULTS

Regarding premorbid and baseline characteristics, woman developed threshold symptoms of a FEP 1 year later than men on average. Women were more likely to be married, men were more likely to live in pension or care home facility or to be homeless. Women displayed a higher rate of history of suicide attempts and exposure to childhood trauma, while men were more likely to have a forensic history, a history of abuse of alcohol and cannabis as well as a dependency to cannabis at the time of entry in TIPP. Regarding evolution, men were more prone to violent acts and were less likely to decrease their usage of substances. The longitudinal analysis highlighted that men displayed greater negative symptoms over the entire treatment period, lower functioning after 6 months and on all assessment points after. Both genders displayed similar rate of improvement in these 3 dimensions over time.

CONCLUSION

Our study confirms that there are some gender differences in the early phase of psychosis that may require differentiation of assessment and treatment to improve recovery.

Adolescent raloxifene treatment in females prevents cognitive deficits in a neurodevelopmental rodent model of schizophrenia

The existence of sex differences in schizophrenia is a well documented phenomenon which led to the hypothesis that female sex hormones are neuroprotective and hence responsible for the more favorable disease characteristics seen in women. The current study sought to investigate the effects of estrogen-like agents administered during early adolescence on behavioral outcomes in adulthood using the neurodevelopmental maternal immune activation (MIA) rodent model of schizophrenia. Female MIA offspring were administered during the asymptomatic period of adolescence with either 17β-estradiol, raloxifene or saline and were tested in late adolescence and adulthood for schizophrenia-related behavioral performance. We report here that whereas adult female MIA offspring exhibited cognitive deficits in the form of retarded spatial learning, the administration of raloxifene during adolescence was sufficient in preventing these deficits and resulted in intact performance in the MIA group.

Sex and gender differences in clinical and functional indices in subjects with schizophrenia and healthy controls: Data from the baseline and 4-year follow-up studies of the Italian Network for Research on Psychoses

Gender differences in clinical and psychosocial aspects of schizophrenia have been widely reported. Findings have not always been consistent, and some of them need further research. In a large sample of community dwelling persons with schizophrenia, we investigated gender differences in clinical, cognitive and functional indices, as well as their changes over a 4-year follow-up and their impact on real-life functioning. Gender differences in personal resources, cognitive and functional indices were explored also in a sample of healthy controls. Men with respect to women had an earlier age of illness onset, a worse premorbid adjustment in the academic domain, more severe avolition, expressive deficit and positive symptoms, lower prevalence of comorbidity for affective disorders, less frequent use of two coping strategies ('religion' and 'use of emotional support') and more frequent positive history of substance and alcohol abuse. In addition, men were more impaired in verbal learning, while women in reasoning/problem solving. Some patterns of gender differences observed in healthy controls were not confirmed in patients. Men's disadvantages in the clinical picture did not translate into a worse outcome. This finding may be related to the complex interplay of several factors acting as predictors or mediators of outcome.

Risk for midlife psychosis in women: critical gaps and opportunities in exploring perimenopause and ovarian hormones as mechanisms of risk

Women show a heightened risk for psychosis in midlife that is not observed in men. The menopausal transition (i.e. perimenopause) and accompanying changes in ovarian hormones are theorized to account for this midlife increase in risk. This narrative review aims to empirically examine these theories by reviewing studies of midlife and perimenopausal psychosis risk in women and potential ovarian hormone mechanisms of effects. Clinical and pre-clinical studies examining the effects of midlife age, menopausal stage, and ovarian hormones across adulthood on psychosis risk were identified. Synthesis of this body of work revealed that the peak ages of midlife psychosis risk in women overlap with the age range of key menopausal stages (especially the perimenopausal transition), although studies directly assessing menopausal stage are lacking. Studies examining ovarian hormone effects have almost exclusively focused on earlier developmental stages and events (e.g. pregnancy, the menstrual cycle) and show increases in psychotic symptoms in women and female rats during periods of lower estradiol levels. Estrogen treatment also tends to enhance the effects of neuroleptics in females across species at various reproductive phases. Initial data are promising in suggesting a role for menopausal stage and ovarian hormones in psychosis risk. However, critical gaps in our knowledge base remain, as there is a tendency to rely on indirect and proxy measures of menopausal status and hormones. Opportunities for future research are discussed with the goal of increasing research in this critical area of women's health.

Schizophrenia Psychosis in Women

A first step towards personalized medicine is to consider whether, for some disorders, the safest and most effective treatment of women needs to differ from standard guideline recommendations developed on the basis of clinical trials conducted, for the most part, in men. A second step is to consider how women’s reproductive stages—pre-pubertal years, menstrual phases, pregnancy trimesters, lactation and postpartum periods, menopausal and postmenopausal/aging status—affect the optimal choice of treatment. This review focuses on these two steps in the treatment of psychosis, specifically schizophrenia. It discusses genetics, precursors and symptoms of schizophrenia, reproductive and associated ethical issues, antipsychotic drug response and adverse effects, substance abuse, victimization and perpetration of violence, and issues of immigration and of co-morbidity. The conclusions, while often based on clinical experience and theoretical considerations rather than strictly on the evidence of randomized controlled trials, are that clinical recommendations need to consider clinical and role differences that exist between men and women and make appropriate correction for age and reproductive status.

Delusional disorders: boundaries of a concept

In 1987, DSM-III introduced the term delusional disorder. In so doing they gave new life to a concept that had predated but was delineated in its modern form by Kraepelin and developed most notably in France in the second and third decades of this century. While the current concept of delusional disorder is defined in a manner that distinguishes it from schizophrenia, a consideration of the evolution of thinking about delusional syndromes in France suggests that current distinctions are based on descriptive convenience rather than any understanding of the mechanisms that might produce phenotypic variations. If the purpose of accurate descriptions is to assist research, this state of affairs would seem unsatisfactory.

Retraction: Caractérisation des premiers épisodes de schizophrénie à partir de bases de données administratives de santé jumelées. [Characterization of First Episodes of Schizophrenia from Combined Administrative Databases]. Beaudoin, M., Potvin, S., Dellazizzo, L., Surprenant, M., Lesage, A., Vanasse, A., Ngamini-Ngui, A.† et Dumais, A. Santé mentale au Québec. 2018 Fall ; 43(2) : 83-105.PMID : 32338687

This corrects the article DOI: https://doi.org/10.7202/1058611ar.

Sex and gender differences in schizophrenic psychoses-a critical review

Many sex and gender differences in schizophrenic psychoses have been reported, but few have been soundly replicated. A stable finding is the later age of onset in women compared to men. Gender differences in symptomatology, comorbidity, and neurocognition seem to reflect findings in the general population. There is increasing evidence for estrogens being psychoprotective in women and for hypothalamic-pituitary-gonadal dysfunction in both sexes.More methodologically sound, longitudinal, multi-domain, interdisciplinary research investigating both sex (biological) and gender (psychosocial) factors is required to better understand the different pathogenesis and etiologies of schizophrenic psychoses in women and men, thereby leading to better tailored treatments and improved outcomes.

Symptomatic thinking: the current state of Phase III and IV clinical trials for cognition in schizophrenia

Research indicates that relieving the cognitive and negative symptoms of schizophrenia is crucial for improving patient quality of life. However effective pharmacotherapies for cognitive and negative symptoms do not currently exist. A review of ongoing Phase III clinical trials indicates that, despite numerous compounds being investigated for cognition in schizophrenia, few are actually novel and most are not backed by empirically driven preclinical research efforts. Based on these trials, and a general disinvestment in development of novel therapies for schizophrenia, the likelihood of a major advancement in treating cognitive differences in schizophrenia does not look promising. Possible ways in which the remaining resources for development of novel treatment for schizophrenia can best be leveraged are discussed.

Oestrogens, prolactin, hypothalamic-pituitary-gonadal axis, and schizophrenic psychoses

Interest is growing in the potential effect of gonadal hormones, prolactin, and the hypothalamic-pituitary-gonadal axis in schizophrenic psychoses. Many studies from clinical, epidemiological, and fundamental research have confirmed that oestradiol, the main component of oestrogens, can have protective effects in schizophrenic psychoses. Furthermore, many patients with schizophrenic psychoses-even in the untreated prodromal stages-have hyperprolactinaemia and gonadal dysfunction, with oestrogen deficiency in women and testosterone deficiency in men. The understanding of the pathogenetic mechanisms underlying these findings could contribute to a better understanding of the aetiopathogenesis of schizophrenic psychoses and improve therapeutic approaches. In this Series paper, we aim to review methodologically sound studies in this area, propose a theory to explain these findings in the context of psychosis, and suggest therapeutic strategies and implications for further research.

Cortisol and BDNF levels in depression within schizophrenia structure: approach to treating

To evaluate the effect of depression on the level of cortisol and BDNF in patients with schizophrenia 25 inpatients, who met the diagnostic criteria for ICD-10 schizophrenia (F20), were examined. The examination included clinical, psychopathological, laboratory and psychometric methods. Patients were examined twice: at admission and after 6 weeks of treatment. It was found that the level of BDNF in schizophrenic patients with depressive symptoms was significantly lower than that of non-depressed patients, and the level of cortisol in patients with depression was significantly higher.

Regional cerebral blood flow in late-onset schizophrenia: a SPECT study using 99mTc-ECD

Progressive disability in schizophrenia has been considered to be associated with onset-age. The objective of this study was to evaluate age onset-related degeneration in rCBF in patients with schizophrenia. We evaluated characteristic changes in brain perfusion by age, gender, medication and clinical symptoms in medicated patients with early-onset (EOS: developed at younger than 40 years old: n = 44) and late-onset (LOS: developed at older than 40 years old: n = 19) schizophrenia and control subjects matched for age and gender (n = 37) using statistical parametric mapping (SPM8) applied to 99mTc-ECD SPECT. We performed SPECT with 99mTc-ECD on the brains of subjects. A voxel-by-voxel group analysis was performed using SPM 8 and ANOVA. rCBF in EOS was found to be reduced in the precentral and inferior frontal gyri; on the other hand, rCBF was reduced in the bilateral postcentral gyrus in LOS. This study revealed a significant difference in brain perfusion between EOS and LOS. The present study might suggest that the characteristic changes in rCBF are related to onset-age in schizophrenia.

Analyzing the influence of BDNF heterozygosity on spatial memory response to 17β-estradiol

The recent use of estrogen-based therapies as adjunctive treatments for the cognitive impairments of schizophrenia has produced promising results; however the mechanism behind estrogen-based cognitive enhancement is relatively unknown. Brain-derived neurotrophic factor (BDNF) regulates learning and memory and its expression is highly responsive to estradiol. We recently found that estradiol modulates the expression of hippocampal parvalbumin-positive GABAergic interneurons, known to regulate neuronal synchrony and cognitive function. What is unknown is whether disruptions to the aforementioned estradiol-parvalbumin pathway alter learning and memory, and whether BDNF may mediate these events. Wild-type (WT) and BDNF heterozygous (+/-) mice were ovariectomized (OVX) at 5 weeks of age and simultaneously received empty, estradiol- or progesterone-filled implants for 7 weeks. At young adulthood, mice were tested for spatial and recognition memory in the Y-maze and novel-object recognition test, respectively. Hippocampal protein expression of BDNF and GABAergic interneuron markers, including parvalbumin, were assessed. WT OVX mice show impaired performance on Y-maze and novel-object recognition test. Estradiol replacement in OVX mice prevented the Y-maze impairment, a Behavioral abnormality of dorsal hippocampal origin. BDNF and parvalbumin protein expression in the dorsal hippocampus and parvalbumin-positive cell number in the dorsal CA1 were significantly reduced by OVX in WT mice, while E2 replacement prevented these deficits. In contrast, BDNF(+/-) mice showed either no response or an opposite response to hormone manipulation in both behavioral and molecular indices. Our data suggest that BDNF status is an important biomarker for predicting responsiveness to estrogenic compounds which have emerged as promising adjunctive therapeutics for schizophrenia patients.

Argyrophilic grain disease as a neurodegenerative substrate in late-onset schizophrenia and delusional disorders

To study the relationship between neurodegenerative diseases including argyrophilic grain disease (AGD) and late-onset schizophrenia and delusional disorders (LOSD; onset ≥40 years of age), we pathologically examined 23 patients with LOSD, 71 age-matched normal controls, and 22 psychiatric disease controls (11 depression, six personality disorder, two bipolar disorders, and three neurotic disorders cases). In all LOSD cases (compared to age-matched normal controls), the frequencies of Lewy body disease (LBD), AGD, and corticobasal degeneration (CBD) were 26.1 % (11.3 %), 21.7 % (8.5 %), and 4.3 % (0.0 %), respectively. There was no case of pure Alzheimer's disease (AD). The total frequency of LBD, AGD, and CBD was significantly higher in LOSD cases than in normal controls. Argyrophilic grains were significantly more severe in LOSD than in controls, but were almost completely restricted to the limbic system and adjacent temporal cortex. In LOSD patients whose onset occurred at ≥65 years of age (versus age-matched normal controls), the frequencies of LBD and AGD were 36.4 % (19.4 %) and 36.4 % (8.3 %), respectively, and AGD was significantly more frequent in LOSD patients than in normal controls. In LOSD patients whose onset occurred at <65 years of age, the frequencies of LBD, AGD, and CBD were 16.7, 8.3, and 8.3 %, comparable to those of age-matched normal controls (10.2, 5.1, and 0.0 %). In all psychiatric cases, delusion was significantly more frequent in AGD cases than in cases bearing minimal AD pathology alone. Given these findings, LOSD patients may have heterogeneous pathological backgrounds, and AGD may be associated with the occurrence of LOSD especially after 65 years of age.

Phenotypic cognitive impairment in late-onset delusional disorder

BACKGROUND

Previous use of heterogeneous diagnostic criteria and insensitive cognitive measures has impeded clarification of the extent and type of cognitive impairment specific to late-onset delusional disorder. We examined whether clinical presentations of late-onset delusional disorder are associated with prodromal or established dementia, and whether it might be a discrete clinical syndrome characterized by its own profile of cognitive impairment.

METHOD

Nineteen patients with late-onset delusional disorder from a hospital psychiatric service and 20 patients with dementia of the Alzheimer's type (AD) from an outpatient memory clinic were recruited in a consecutive case series. All patients underwent comprehensive neuropsychological assessment that included general intellectual function, executive function, new learning and delayed memory, language, processing speed, and visuo-perceptual skills.

RESULTS

Late-onset delusional disorder patients showed moderate impairment to conceptual reasoning, visual object recognition, processing speed, and confrontation naming. Severe impairment appeared in visuo-perceptual planning and organization, and divided attention. Compared with the Alzheimer's disease (AD) group, the late-onset delusional disorder group demonstrated significantly poorer visuo-perceptual skills but a significantly better capacity to consolidate information into delayed memory.

CONCLUSIONS

A high rate of marked cognitive impairment occurs in late-onset delusional disorder. There was evidence of a conceptual reasoning deficit, plus the presence of a visuo-perceptual impairment affecting object recognition. This impairment profile can explain the genesis and maintenance of the observed delusions. Understanding late-onset delusional disorder as other than a purely psychiatric phenomenon or a precursor to AD will lead to better assessment and management approaches.

Clinical features of late-onset schizophrenia in Japan: comparison with early-onset cases

BACKGROUND

Although the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders abandoned the use of the specifier 'late-onset', a considerable number of studies have reported clinical characteristics of late-onset schizophrenia. Still, only limited research has been conducted on late-onset schizophrenia, especially in Asian countries. In this epidemiological study, the clinical characteristics of late-onset schizophrenia were examined in comparison with early-onset schizophrenia.

METHODS

All patients with schizophrenia admitted to the psychiatric ward of Jichi Medical University Hospital between 1 April 1993 and 31 March 2006 were divided into two groups according to age at first onset: ≥40 years (late-onset group) and <40 years (early-onset group). The sex ratio, presence or absence of depression, schizophrenia subtype, premorbid character, marital history, and employment history at first onset were compared between the two groups.

RESULTS

Of the 316 patients with schizophrenia identified, 38 patients were assigned to the late-onset group and 278 patients to the early-onset group. Mean age at onset was 23.9 ± 8.2 years for all men and 28.0 ± 13.5 years for all women. The late-onset group was characterized by more women, more paranoid type, more depressive symptoms, less introverted premorbid character, better premorbid adaptation and less neuroleptics.

CONCLUSION

The characteristics of late-onset schizophrenia in Japan are in line those reported previously.

Assessing Diagnosis and Symptoms Profiles of Late-Life Psychosis

Background: There are many controversies with regard to the nosology and conditions causing psychosis in old age people. This study defines a symptom profile and differential diagnosis of late-onset psychosis. Method: 201 elderly persons with psychotic symptoms were recruited. All patients were interviewed based on SCID-1 to confirm the possible diagnosis. Results: The most delusional symptom reported by the subjects was persecutory delusion, and visual hallucinations were the most common hallucination. The most repeated diagnosis was dementia, followed by psychosis due to mood disorders, primary psychotic disorders, delirium, and psychosis due to medical conditions. Conclusions: Results from the current study indicate that late-life psychoses form a heterogeneous group of disorders with varying symptom profiles and etiologies.

Dendritic spine pathology in schizophrenia

Schizophrenia is a neurodevelopmental disorder whose clinical features include impairments in perception, cognition and motivation. These impairments reflect alterations in neuronal circuitry within and across multiple brain regions that are due, at least in part, to deficits in dendritic spines, the site of most excitatory synaptic connections. Dendritic spine alterations have been identified in multiple brain regions in schizophrenia, but are best characterized in layer 3 of the neocortex, where pyramidal cell spine density is lower. These spine deficits appear to arise during development, and thus are likely the result of disturbances in the molecular mechanisms that underlie spine formation, pruning, and/or maintenance. Each of these mechanisms may provide insight into novel therapeutic targets for preventing or repairing the alterations in neural circuitry that mediate the debilitating symptoms of schizophrenia.

Personality disorders in later life: questions about the measurement, course, and impact of disorders

Lifespan perspectives have played a crucial role in shaping our understanding of many forms of psychopathology. Unfortunately, little attention has been given to personality disorders in middle adulthood and later life. Several issues are responsible for this deficiency, including difficulty applying the diagnostic criteria for personality disorders to older people and challenges in identifying appropriate samples of older participants. The goal of this review is to explore the benefits of considering older adults in the study of personality disorders. Later life offers a unique opportunity for investigators to consider links between personality pathology and consequential outcomes in people's lives. Many domains are relevant, including health, longevity, social adjustment, marital relationships, and the experience of major life events. We review each domain and consider ways in which the study of middle-aged and older adults challenges researchers to evaluate how personality disorders in general are defined and measured.

Estrogens and gonadal function in schizophrenia and related psychoses

Recent research has increasingly pointed to the importance of estrogens and the hypothalamic-pituitary-gonadal axis in schizophrenia. Specifically, there is mounting evidence from clinical, epidemiological, and basic research that estradiol, the main component of estrogens, exerts protective effects in schizophrenia and related psychoses. Possible modes of action of this hormone in the brain have been suggested, and clinical intervention studies have reported the first positive results. Furthermore, there are an increasing number of reports on gonadal dysfunction and states of estrogen deficiency in women with schizophrenia. These findings could have important implications for clinicians and researchers alike.

Is late-onset schizophrenia a subtype of schizophrenia?

OBJECTIVE

To determine whether late-onset schizophrenia (LOS, onset after age 40) should be considered a distinct subtype of schizophrenia.

METHOD

Participants included 359 normal comparison subjects (NCs) and 854 schizophrenia out-patients age >40 (110 LOS, 744 early-onset schizophrenia or EOS). Assessments included standardized measures of psychopathology, neurocognition, and functioning.

RESULTS

Early-onset schizophrenia and LOS groups differed from NCs on all measures of psychopathology and functioning, and most cognitive tests. Early-onset schizophrenia and LOS groups had similar education, severity of depressive, negative, and deficit symptoms, crystallized knowledge, and auditory working memory, but LOS patients included more women and married individuals, had less severe positive symptoms and general psychopathology, and better processing speed, abstraction, verbal memory, and everyday functioning, and were on lower antipsychotic doses. Most EOS-LOS differences remained significant after adjusting for age, gender, severity of negative or deficit symptoms, and duration of illness.

CONCLUSION

Late-onset schizophrenia should be considered a subtype of schizophrenia.

Clinical characterization of late- and very late-onset first psychotic episode in psychiatric inpatients

OBJECTIVES

The goals of this study were to investigate the prevalence and initial symptoms of the late-onset schizophrenia (LOS: >40 years) and very-late-onset schizophrenia-like psychosis (VLOSLP: >60 years) nosological groups proposed by the International Late-Onset Schizophrenia Group.

DESIGN

This was a retrospective, cross-sectional, chart review study.

SETTING

The study was conducted at Centre Hospitalier Robert-Giffard (CHRG), Quebec City, Canada.

PATIENTS

The medical records of inpatients from the CHRG who presented with psychotic symptoms were analyzed.

MEASUREMENTS

Positive and negative symptoms were scored using the SAPS and SANS. Groups' symptoms were compared using chi(2), Fisher's exact tests, t tests, and exact Mann-Whitney tests. An exact conditional logistic regression analysis was performed to determine which clinical characteristics were the most predictive of the groups' classification.

RESULTS

Among the 1,767 unique, first-admission medical records reviewed, 23 (1.3%) inpatients developed their first psychotic symptoms at the age of 40-59 years old (LOS), and 13 (0.7%) at the age of 60 years and above (VLOSLP). LOS patients were more apathetic and presented more abnormal psychomotor activity than the VLOSLP. Persecutory delusions, auditory hallucinations, inappropriate social behavior, formal thought disorders and anhedonia were frequent in the two groups. A logistic regression model including psychomotor abnormalities was statistically relevant to predict the belonging to LOS group.

CONCLUSION

LOS and VLOSLP are rare. Abnormal psychomotor activity can properly differentiate VLOSLP and LOS. The nosological model proposed by the International Late-Onset Schizophrenia Group is at least partially supported by the present data.

Psychosis risk as a function of age at onset: a comparison between early- and late-onset psychosis in a general population sample

BACKGROUND

Little is known about late-onset psychosis (onset after the age 45 years) and how it relates to early-onset psychosis (before age 45 years). The aims of this study were to calculate the incidence of non-affective, non-organic psychotic symptoms across the life span and to explore the contribution of different sets of risk factors in relation to age at onset.

METHODS

Data were obtained from the three measurements of the Netherlands Mental Health Survey and Incidence Study. Symptoms of psychosis were assessed in individuals aged 18-64 years using the Composite International Diagnostic Interview. All individuals reporting first-onset of psychotic symptoms within a three-year interval were included. The degree to which sets of risk factors affected the psychosis outcome similarly across age groups was assessed.

RESULTS

The number of subjects displaying incident psychotic symptoms was similar across age groups. Cumulative incidence rates ranged from 0.3% to 0.4%. Age differences were found for life-time depressive symptoms (risk difference = 5%, 95% CI = 1%, 9%) and baseline neuroticism (risk difference = 3%, 95% CI = 0%, 6%), indicating that late-onset psychosis was less often preceded by these. In contrast, no effect modification by age was observed for female sex, hearing impairment, being single, or life-time cannabis use.

CONCLUSIONS

Onset of psychotic symptoms in late life is no rare event. Compared to early onset psychosis, the late-onset counterpart less often arises in a context of emotional dysfunction and negative affectivity, suggesting qualitative differences in aetiology and more effective premorbid coping styles.

Relationship between estrogen and schizophrenia

There is a wealth of historical and circumstantial evidence to suggest that female patients with schizophrenia may suffer from a deficit in estrogenic function. The prolactin-inducing properties of most antipsychotic drugs, and subsequent negative feedback on estrogen levels, is in keeping with this. The functions of estrogen, its complex receptor organization and its numerous actions are the focus of ongoing research activity. Of particular interest are its neuroprotective properties, particularly with regard to cognitive impairment, and its involvement with neurotransmitter systems, which are the substrate for psychotropic drugs. Estrogen has now been used as an adjunct to standard antipsychotic medication in quite a few studies of female schizophrenia patients. However, most of these are not double-blind, randomized, controlled trials. Only two relatively small double-blind, randomized clinical trials returned positive results: one long-term study that selected for hypoestrogenism reported negative findings. Furthermore, recent evidence of the risks of long-term hormone replacement therapy is of concern. The advent of specific estrogen receptor modulators, which may avoid excess risks of cancer and cardiovascular events, will have little to add to schizophrenia treatment if estrogen is, essentially, devoid of any specific antipsychotic or adjuvant mechanism of action relevant to the pathophysiology of this disorder.

Size of burden of schizophrenia and psychotic disorders

Schizophrenia is a severe mental disorder characterised by fundamental disturbances in thinking, perception and emotions. More than 100 years of research have not been able to fully resolve the puzzle that schizophrenia represents. Even if schizophrenia is not a very frequent disease, it is among the most burdensome and costly illnesses worldwide. It usually starts in young adulthood. Life expectancy is reduced by approximately 10 years, mostly as a consequence of suicide. Even if the course of the illness today is considered more favourable than it was originally described, it is still only a minority of those affected, who fully recover. The cumulative lifetime risk for men and women is similar, although it is higher for men in the age group younger than 40 years. According to the Global Burden of Disease Study, schizophrenia causes a high degree of disability, which accounts for 1.1% of the total DALYs (disability-adjusted life years) and 2.8% of YLDs (years lived with disability). In the World Health Report [The WHO World Health Report: new understanding, new hope, 2001. Geneva], schizophrenia is listed as the 8th leading cause of DALYs worldwide in the age group 15-44 years. In addition to the direct burden, there is considerable burden on the relatives who care for the sufferers. The treatment goals for the moment are to identify the illness as early as possible, treat the symptoms, provide skills to patients and their families, maintain the improvement over a period of time, prevent relapses and reintegrate the ill persons into the community so that they can lead as normal a life as possible.

Psychopathology of early-onset versus late-onset schizophrenia revisited: an observation of 473 neuroleptic-naive patients before and after first-admission treatments

Reports of potential differences in psychopathological presentations between early and late-onset schizophrenia have been controversial. However, such differences in first-episode neuroleptic-naive schizophrenic patients have not been discussed. The authors evaluated symptom profiles in 473 neuroleptic-naive schizophrenic patients before and after first-admission treatments. Both before and after treatment, (1) late-onset schizophrenia had a lower score on affective flattening/social withdrawal than did the earlier-onset counterpart of the illness, even after controlling for potential secondary sources of negative symptoms; (2) systematic persecutory delusion was more severe in patients with late-onset schizophrenia; and (3) the overall effect of age of onset on the psychopathological presentations was greater than the gender-related effects, including the interaction between age of onset and gender. Consideration of late-onset schizophrenia may be important in order to develop an etiologically and clinically reasonable conceptualization of the subtypes of schizophrenia. A factor-analytical study that attempts to compare directly the structure of broad psychopathological presentations in early and late-onset schizophrenia may be a reasonable approach to investigate the longstanding unsolved controversy as to whether or not the neurobiological backgrounds underlying the psychopathological presentations are comparable.

Psychosis in elderly patients: classification and pharmacotherapy

Psychosis in elderly patients is a growing clinical concern because psychotic symptoms most frequently occur as noncognitive manifestations of Alzheimer's disease, as side effects of drug therapy for Parkinson's disease, or as the primary abnormalities in schizophrenia, and the clinical characteristics of psychosis are distinct for each. In planning antipsychotic pharmacotherapy for elderly patients, age-related pharmacokinetic changes, polypharmacy for comorbid diseases, and concerns about the underlying conditions responsible for the psychotic symptoms must be considered. Traditional antipsychotic agents bind to dopamine receptors and effectively relieve positive schizophrenic symptoms but frequently cause tardive dyskinesia and other extrapyramidal symptoms, a problem for elderly patients, particularly for those with Parkinson's disease. Atypical antipsychotics bind to dopamine and serotonin receptors, relieving both positive and negative symptoms, and are less likely to cause extrapyramidal symptoms. The authors review common diagnostics associated with psychosis in the elderly and clinical guidelines to selecting antipsychotic pharmacotherapy.

Gender aspects in schizophrenia: bridging the border between social and biological psychiatry

OBJECTIVE

This paper tries to show that gender differences in mental diseases are a valuable paradigm for research into the interplay between biological and psychosocial factors--not only regarding pathogenetic mechanisms, but also concerning therapeutic approaches.

METHOD

Based on relevant literature, this topic is highlighted using schizophrenia as an example.

RESULTS

Schizophrenic disorders show a later age of onset in women and a slightly better course, especially in young women. As to pathogenesis, there is some evidence that the age difference might be due at least partly to the female sex hormone oestradiol being a protective factor. Differences in course might also have to do with this biological factor, but at the same time with the psychosocial advantages of a higher age of onset and other psychosocial factors. Concerning therapy, these gender differences have important implications for pharmacotherapy, but also psychotherapy and social measures.

CONCLUSION

A gender-sensitive approach in psychiatry improves our understanding of mental illness and our therapeutic strategies and at the same time illustrates that comprehensive psychiatry cannot be practised in artificially separated 'drawers' called 'biological psychiatry', on one hand, and 'social psychiatry' on the other.

[Not Available]

A gender-sensitive psychiatry and psychotherapy takes into account the characteristics of mental disorders in both genders, in diagnostics as well as in therapy. It thereby not only contributes to quality assurance in our practical work, but also to patient-satisfaction. Teaching and training in this area have, so far, been neglected in German speaking countries, and research is also mainly done in Angloamerican countries. But especially in this area, findings cannot easily be transferred from one culture to another. Furthermore, research on gender differences and influencing factors - biological, psychological and social ones - as well as their interactions are of outstanding importance for research on mental disorders in general.

Serum levels of soluble IL-2 receptor alpha, IL-6 and IL-1 receptor antagonist in schizophrenia before and during neuroleptic administration

Serum levels of interleukin-2 soluble receptor alpha (IL-2sR alpha), interleukin-6 (IL-6) and interleukin-1 receptor antagonist (IL-1ra) were determined both before and during neuroleptic administration in an 8-week treatment protocol for schizophrenia. In comparison with a control group, schizophrenia patients showed significantly higher serum levels of IL-2sR alpha, IL-6 and IL-1ra at weeks 0, 1, 4 and 8, and there was a significant negative correlation between the serum level of IL-2sR alpha at week 1 and the age at illness onset. Those of the schizophrenia patients who were neuroleptic-naive had significantly higher pretreatment serum levels of IL-2sR alpha, IL-6 and IL-1ra than the controls. There were significant positive correlations between the IL-2sR alpha levels at weeks 0 and 1, and the psychopathology scores, evaluated using the positive and negative syndrome scale at week 4. IL-6 levels at weeks 0, 1 and 4 were significantly and positively correlated with the duration of illness. The IL-1ra level at week 1 was significantly and positively correlated with positive symptoms at week 1. The present study supports the suggestion that changes in the immune system are involved in the pathophysiology of schizophrenia.

Late paraphrenia: a variant of schizophrenia manifest in late life or an organic clinical syndrome? A review of recent evidence

A large amount of research has been devoted during the past 15 years to the clinical and neurobiological aspects of the disorder named as 'late paraphrenia' (LP) in 1955. The symptomatology and diagnosis of the disorder, its prognosis, the cognitive functioning of those affected, the structural changes in the brain as revealed by modern techniques of brain imaging and its postmortem neuropathology have all been submitted to investigation. The results have been widely regarded as consistent with the concept of LP as an organic disease of the brain, but increased knowledge of the neurobiology of schizophrenia and of the age-related changes that occur in the brains of elderly people casts doubt on the validity of this interpretation. The findings are consistent with the view that LP is the form in which schizophrenia is manifest in old age. The proposal that LP has a closer kinship with affective disorder than with schizophrenia is part of a general theory of the sex differences in schizophrenia. In LP it becomes entangled with the organicity hypothesis, suggesting that neither of these explanations is adequate, and most of the evidence points to a unitary concept which views LP as a variant of a single disorder, namely schizophrenia, which, however, requires a broad definition. This concept has implications for fresh paths of enquiry.