Treating Negative Symptoms in Schizophrenia: an Update. ACTA ACUST UNITED AC. 2016;3:133-150. [PMID: 27376016 PMCID: PMC4908169 DOI: 10.1007/s40501-016-0075-8]

Prevalence and predictors of metabolic syndrome among psychiatric patients receiving antipsychotic treatment in Africa: a systematic review and meta-analysis

BACKGROUND

Antipsychotic medications, though essential for treating severe mental illnesses, are commonly associated with metabolic side effects that increase the risk of metabolic syndrome (MetS). These metabolic complications significantly undermine treatment adherence and contribute to adverse clinical outcomes. Despite the increasing utilization of antipsychotics in Africa, there remains a critical lack of region-specific data on the prevalence and determinants of metabolic syndrome in this population. This systematic review and meta-analysis aims to synthesize existing data on the prevalence and predictors of MetS among psychiatric patients receiving antipsychotic treatment in Africa.

METHOD

We looked for primary papers on PubMed/MEDLINE, Scopus, African Journal Online, PsycINFO, EMBASE, Psychiatry Online, CINAHL, Science Direct, and the Cochrane Library. We included original research articles that evaluated the prevalence of metabolic syndrome among psychiatric patients treated with antipsychotic medication. Two independent reviewers examined the articles and extracted data. The I² statistic was employed to assess statistical heterogeneity, and a random-effects meta-analysis was applied due to the observed heterogeneity. Publication bias was evaluated using a funnel plot and Egger's weighted regression test. This review has been registered with PROSPERO (ID = CRD42024558310).

RESULTS

This systematic review analyzed 25 primary studies encompassing a total of 4,064 participants. The pooled prevalence of metabolic syndrome among psychiatric patients receiving antipsychotic treatment in Africa was estimated at 22% (95% CI: 16.33-27.66). Female gender (OR = 3.28, 95% CI: 1.73-6.23), advanced age (OR = 1.07, 95% CI: 1.03-1.12), and elevated body mass index (OR = 5.33, 95% CI: 2.35-12.12) were identified as significant risk factors for metabolic syndrome in this population.

CONCLUSION

Metabolic syndrome is highly prevalent among psychiatric patients receiving antipsychotic treatment in Africa, with female sex, older age, and elevated body mass index identified as significant risk factors. These findings underscore the need for routine metabolic monitoring and timely interventions to mitigate cardiovascular risk, enhance treatment adherence, and prevent recurrence of psychiatric symptoms.

Measuring the clinical dimensions of negative symptoms through the Positive and Negative Syndrome Scale

The negative symptoms of schizophrenia can determine functional outcome in patients. Despite its clinical significance, no treatment exists to date, as numerous pharmacological and non-pharmacological clinical trials have failed to demonstrate efficacy. Many of these trials evaluated negative symptoms as a single clinical construct. However, consistent evidence in the past two decades has found that negative symptoms constitute at least two independent clinical dimensions, namely deficits in motivation and pleasure (MAP) and in emotional expression (EXP). These dimensions are best evaluated using new assessment tools, such as the Brief Negative Symptom Scale (BNSS). However, older assessment tools, and particularly the Positive and Negative Syndrome Scale (PANSS), remain widely used in past and current research. Here, we sought to predict BNSS MAP and EXP dimensions from the PANSS. Using complementary modelling approaches across three heterogeneous, multi-centre, multi-culture patient samples (n = 1241 patients, 1846 observations), we show that MAP can be estimated (43-60 % variance explained) predominantly using N2 and N4. Moreover, EXP can be estimated predominantly using the two PANSS items N1 and N6 (55-81 % variance explained across models and samples). Additionally, PANSS-derived MAP shows associations with functioning similar to those measured by the BNSS MAP dimension. Together, our results suggest that while EXP can be reliably estimated from PANSS, MAP cannot be consistently estimated from PANSS across samples and cultures. This warrants caution when using the PANSS to estimate MAP and emphasises the need for using the newer assessment tools for negative symptoms.

Revisiting the Defeatist Performance Belief Scale in Adults With Schizophrenia and Youth at Clinical High-Risk for Psychosis: A Comprehensive Psychometric Analysis

BACKGROUND AND HYPOTHESIS

In accordance with the Cognitive Model of Negative Symptoms, defeatist performance beliefs (DPBs) are an important psychosocial mechanism of negative symptoms in schizophrenia-spectrum groups. DPBs are also mediators of negative symptom improvement in clinical trials. Despite the clinical significance of DPBs and their inclusion as a mechanism of change measure in clinical trials, the psychometric properties of the DPB scale have not been examined in any schizophrenia-spectrum group.

STUDY DESIGN

This study evaluated the factor structure, reliability, and validity of the DPB scale in 943 schizophrenia and 250 clinical high-risk for psychosis (CHR) participants from multiple US sites. Confirmatory factor analyses tested competing factor structures: a unidimensional model-consistent with how DPBs are currently assessed-and multifactorial models with up to 4 factors identified with exploratory factor analyses.

STUDY RESULTS

Models with 3 and 4 factors provided superior fit compared to the unidimensional model, with an advantage for the 3-factor model. The 3-factor model, consisting of Overvaluing Success, Overvaluing Failure, and Overvaluing Social Evaluation factors, demonstrated good replicability, temporal stability, and measurement invariance in schizophrenia and CHR samples. Convergent validity was demonstrated via significant correlations with negative symptoms and functioning, but limited associations were present with neurocognition. Discriminant validity was supported by low correlations with positive symptoms.

CONCLUSIONS

Findings support the validity and reliability of the 3-factor structure of the DPB scale across phases of psychosis. Use of a 3-factor structure may clarify the most critical DPB targets for negative symptom treatment and early prevention and intervention.

Neuroinflammatory Loop in Schizophrenia, Is There a Relationship with Symptoms or Cognition Decline?

Schizophrenia (SZ), a complex psychiatric disorder of neurodevelopment, is characterised by a range of symptoms, including hallucinations, delusions, social isolation and cognitive deterioration. One of the hypotheses that underlie SZ is related to inflammatory events which could be partly responsible for symptoms. However, it is unknown how inflammatory molecules can contribute to cognitive decline in SZ. This review summarises and exposes the possible contribution of the imbalance between pro-inflammatory and anti-inflammatory interleukins like IL-1beta, IL-4 and TNFalfa among others on cognitive impairment. We discuss how this inflammatory imbalance affects microglia and astrocytes inducing the disruption of the blood-brain barrier (BBB) in SZ, which could impact the prefrontal cortex or associative areas involved in executive functions such as planning and working tasks. We also highlight that inflammatory molecules generated by intestinal microbiota alterations, due to dysfunctional microbial colonisers or the use of some anti-psychotics, could impact the central nervous system. Finally, the question arises as to whether it is possible to modulate or correct the inflammatory imbalance that characterises SZ, and if an immunomodulatory strategy can be incorporated into conventional clinical treatments, either alone or in complement, to be applied in specific phases, such as prodromal or in the first-episode psychosis.

Alterations of the IKZF1-IKZF2 tandem in immune cells of schizophrenia patients regulate associated phenotypes

Schizophrenia is a complex multifactorial disorder and increasing evidence suggests the involvement of immune dysregulations in its pathogenesis. We observed that IKZF1 and IKZF2, classic immune-related transcription factors (TFs), were both downregulated in patients' peripheral blood mononuclear cells (PBMCs) but not in their brain. We generated a new mutant mouse model with a reduction in Ikzf1 and Ikzf2 to study the impact of those changes. Such mice developed deficits in the three dimensions (positive-negative-cognitive) of schizophrenia-like phenotypes associated with alterations in structural synaptic plasticity. We then studied the secretomes of cultured PBMCs obtained from patients and identified potentially secreted molecules, which depended on IKZF1 and IKZF2 mRNA levels, and that in turn have an impact on neural synchrony, structural synaptic plasticity and schizophrenia-like symptoms in in vivo and in vitro models. Our results point out that IKZF1-IKZF2-dependent immune signals negatively impact on essential neural circuits involved in schizophrenia.

Crocus sativus (saffron) adjunct to risperidone for negative symptoms of schizophrenia: a randomized, double-blind, placebo-controlled trial

Current treatments for schizophrenia encounter resistance, limited efficacy, and limiting complications, necessitating novel approaches. The effects of saffron on negative symptoms were investigated as it has shown neuroprotective and antipsychotic properties. Fifty-six clinically stable chronic schizophrenic outpatients were equally assigned to saffron 15 mg q12hr or placebo groups while continuing risperidone. The Positive and Negative Syndrome Scale (PANSS) was used to assess schizophrenia-related symptoms in weeks 4 and 8. Also, the patients were assessed for the Hamilton depression rating scale (HDRS) and adverse effects. The baseline characteristics of the groups were comparable (Ps > 0.05). There were significant time-treatment interaction effects on negative ( = 0.137), general psychopathology ( = 0.193), and total ( = 0.113) PANSS scores. Affirmatively, their reductions were significantly greater in the saffron group until weeks 4 (Cohen's ds = 0.922, 0.898, and 0.759, respectively) and 8 (Cohen's ds = 0.850, 1.047, and 0.705, respectively). Regarding the negative symptoms, a better 25% response rate was obtained in the saffron group until the endpoint (P = 0.003). The HDRS scores, extrapyramidal symptom rating scale scores, and side effect frequencies were comparable between the groups (Ps > 0.05). Saffron was beneficial for primary negative symptoms of chronic schizophrenia in a safe and tolerable manner. It also outperformed placebo in improving general psychopathology and total symptoms.

Cerebellar-Prefrontal Connectivity Predicts Negative Symptom Severity Across the Psychosis Spectrum

Background

Negative symptom severity predicts functional outcome and quality life in people with psychosis. However, negative symptoms are poorly responsive to antipsychotic medication and existing literature has not converged on their neurobiological basis. Previous work in small schizophrenia samples has observed that lower cerebellar-prefrontal connectivity is associated with higher negative symptom severity and demonstrated in a separate neuromodulation experiment that increasing cerebellar-prefrontal connectivity reduced negative symptom severity. We sought to expand this finding to test associations between cerebellar-prefrontal connectivity with negative symptom severity and cognitive performance in a large, transdiagnostic sample of individuals with psychotic disorders.

Methods

In this study, 260 individuals with psychotic disorders underwent resting-state MRI and clinical characterization. Negative symptom severity was measured using the Positive and Negative Symptoms Scale, and cognitive performance was assessed with the Screen for Cognitive Impairment in Psychiatry. Using a previously identified cerebellar region as a seed, we performed seed to whole brain analyses and regressed connectivity against negative symptom severity, using age and sex as covariates.

Results

Consistent with prior work, we identified relationships between higher cerebellar-prefrontal connectivity and lower negative symptom severity (r=-0.17, p=.007). Higher cerebellar-prefrontal connectivity was also associated with better delayed verbal learning (r=.13, p=.034).

Conclusions

Our results provide further evidence supporting the relationship between cerebellar-prefrontal connectivity and negative symptom severity and cognitive performance. Larger, randomized, sham-controlled neuromodulation studies should test if increasing cerebellar-prefrontal connectivity leads to reductions in negative symptoms in psychosis.

The Role of Defeatist Performance Beliefs in State Fluctuations of Negative Symptoms in Schizophrenia Measured in Daily Life via Ecological Momentary Assessment

BACKGROUND AND HYPOTHESIS

The Cognitive Model of Negative Symptoms is a prominent model that posits that defeatist performance beliefs (DPB) are a key psychological mechanism underlying negative symptoms in those with schizophrenia (SZ). However, the ecological validity of the model has not been established, and temporally specific evaluations of the model's hypotheses have not been conducted. This study tested the model's key hypotheses in real-world environments using ecological momentary assessment (EMA).

STUDY DESIGN

Fifty-two outpatients with SZ and 55 healthy controls (CN) completed 6 days of EMA. Multilevel models examined concurrent and time-lagged associations between DPB and negative symptoms in daily life.

STUDY RESULTS

SZ displayed greater DPB in daily life than CN. Furthermore, greater DPB were associated with greater concurrently assessed negative symptoms (anhedonia, avolition, and asociality) in daily life. Time-lagged analyses indicated that in both groups, greater DPB at time t led to elevations in negative symptoms (anhedonia, avolition, or asociality) at t + 1 above and beyond the effects of negative symptoms at time t.

CONCLUSIONS

Results support the ecological validity of the Cognitive Model of Negative Symptoms and identify a temporally specific association between DPB and subsequent negative symptoms that is consistent with the model's hypotheses and a putative mechanistic pathway in Cognitive Behavioral Therapy for negative symptoms. Findings suggest that DPB are a psychological factor contributing to negative symptoms in real-world environments. Implications for measuring DPB in daily life and providing just-in-time mobile health-based interventions to target this mechanism are discussed.

Mitochondrial dysfunction in psychiatric disorders

Psychiatric disorders are a heterogeneous group of mental disorders with abnormal mental or behavioral patterns, which severely distress or disable affected individuals and can have a grave socioeconomic burden. Growing evidence indicates that mitochondrial function plays an important role in developing psychiatric disorders. This review discusses the neuropsychiatric consequences of mitochondrial abnormalities in both animal models and patients. We also discuss recent studies associated with compromised mitochondrial function in various psychiatric disorders, such as schizophrenia (SCZ), major depressive disorder (MD), and bipolar disorders (BD). These studies employ various approaches including postmortem studies, imaging studies, genetic studies, and induced pluripotent stem cells (iPSCs) studies. We also summarize the evidence from animal models and clinical trials to support mitochondrial function as a potential therapeutic target to treat various psychiatric disorders. This review will contribute to furthering our understanding of the metabolic etiology of various psychiatric disorders, and help guide the development of optimal therapies.

Adjunctive methylphenidate extended release in patients with schizophrenia: Protocol of a single-centre fixed dose cross-over open-label trial to improve functional and cognitive outcomes

Background

Cognitive symptoms, among the core symptoms of schizophrenia, are associated with poor functional outcome and burden of illness. To date, there is no effective pharmacological treatment for these symptom clusters. Augmentation with psychostimulants has been proposed as a potential treatment option.

Objectives

The present study aims to assess off-label use of adjunctive methylphenidate extended release (ER) in patients with schizophrenia who are stable on antipsychotic medications, and to assess its efficacy on functioning and cognitive outcome.

Methods

This is a single centre study at the Royal Ottawa Mental Health Centre. An open-label fixed dose controlled cross-over trial is planned. Eligible participants will be randomized into one of two arms of the study: 1) four weeks of add-on methylphenidate ER 36 mg, or 2) four weeks of treatment as usual. At 4 weeks, participants will switch arms. The duration of the study includes 8 weeks of treatment and a follow-up visit at 12 weeks. Primary outcome measures include tablet-based tests of functioning and cognition (VRFCAT and BAC) and will be administered at baseline and every 4 weeks. We are aiming to recruit a total of 24 participants.

Expected outcomes

The proposed project intends to assess a potential treatment option for cognitive deficits of schizophrenia, for which there are no recommendations by current treatment guidelines. The novelty and significance of the current study is that it investigates this intervention and assess applicability of it in a "real world setting" in a tertiary care hospital.

Personalised transcranial magnetic stimulation for treatment-resistant depression, depression with comorbid anxiety and negative symptoms of schizophrenia: a narrative review

ABSTRACT

Transcranial magnetic stimulation (TMS) is a promising intervention for treatment-resistant psychiatric disorders. However, conventional TMS typically utilises a one-size-fits-all approach when determining stimulation targets. Recent retrospective brain circuit-based analyses using lesion network mapping have suggested that a left dorsal lateral prefrontal cortex target has a higher efficacy for alleviating depression symptoms, a dorsomedial prefrontal cortex target is more effective for anxiety symptoms, and a rostromedial prefrontal cortex target is effective for schizophrenia-associated psychiatric symptoms. Nonetheless, symptom-specific brain circuit targeting has not been tested prospectively. We conducted a narrative review of selected literature to investigate individualised targeting for TMS and discuss potential future directions to elucidate the efficacy of this approach.

Hippocampal Pyk2 regulates specific social skills: Implications for schizophrenia

Pyk2 has been shown previously to be involved in several psychological and cognitive alterations related to stress, Huntington's disease, and Alzheimer's disease. All these disorders are accompanied by different types of impairments in sociability, which has recently been linked to improper mitochondrial function. We hypothesize that Pyk2, which regulates mitochondria, could be associated with the regulation of mitochondrial dynamics and social skills. In the present manuscript, we report that a reduction of Pyk2 levels in mouse pyramidal neurons of the hippocampus decreased social dominance and aggressivity. Furthermore, social interactions induced robust Pyk2-dependent hippocampal changes in several oxidative phosphorylation complexes. We also observed that Pyk2 levels were increased in the CA1 pyramidal neurons of schizophrenic subjects, occurring alongside changes in different direct and indirect regulators of mitochondrial function including DISC1 and Grp75. Accordingly, overexpressing Pyk2 in hippocampal CA1 pyramidal cells mimicked some specific schizophrenia-like social behaviors in mice. In summary, our results indicate that Pyk2 might play a role in regulating specific social skills likely via mitochondrial dynamics and that there might be a link between Pyk2 levels in hippocampal neurons and social disturbances in schizophrenia.

Pupillary responses as a biomarker of cognitive effort and the impact of task difficulty on reward processing in schizophrenia

Negative symptoms of schizophrenia robustly predict functional outcomes but remain relatively resistant to available treatments. Better measures of negative symptoms, especially motivational deficits, are needed to better understand these symptoms and improve treatment development. Recent research shows promise in linking behavioral effort tasks to motivational negative symptoms, reward processing deficits, and defeatist attitudes, but few studies account for individual or group (patient v. control) differences in cognitive ability to perform the tasks. Individuals with poorer abilities might be less motivated to perform tasks because they find them more difficult to perform. This study used a personalized digit span task to control task difficulty while measuring task effort via pupillary responses (greater dilation indicates greater cognitive effort) at varying monetary rewards ($1 & $2). Participants with schizophrenia (N = 34) and healthy controls (N = 41) performed a digit span task with personalized max span lengths and easy (max- 2 digits) and overload (max+ 2 digits) conditions. Consistent with many studies, pupillary responses (cognitive effort) increased with greater difficulty until exceeding capacity. A similar pattern of reward responsivity was seen in both groups, such that greater reward increased dilation (effort) comparably for both groups when difficulty was within capacity. Neither patients nor controls exerted increased effort for greater reward when difficulty exceeded capacity. In patients, positive relationships were found between pupil dilation and defeatist performance beliefs if task difficulty was within capacity; a relationship that reversed if the task was too difficult. The findings demonstrate the importance of accounting for cognitive capacity and task difficulty when evaluating motivation and reward sensitivity and illustrate the utility of pupillary responses as an objective measure of effort in schizophrenia.

The combination of oxytocin and mindfulness-based group therapy for empathy and negative symptoms in schizophrenia spectrum disorders - A double-blinded, randomized, placebo-controlled pilot study

Treatment options for social cognition and negative symptoms in schizophrenia spectrum disorders (SSD) remain limited. Oxytocin could be a promising augmentation approach, but the social context influences the effect in humans. This pilot study hypothesized that oxytocin in a positive social setting through mindfulness-based group therapy (MBGT) would positively affect empathy and negative symptoms as well as affect and stress in an exploratory approach in SSD. An experimental, randomized, double-blinded (participants, psychotherapists), placebo-controlled pilot study with 41 individuals with SSD was conducted at the Charité - Universitätsmedizin Berlin. Oxytocin or placebo (24 I.U.) was administered intranasally 45 min before two sessions of MBGT each. A 2 × 2 mixed model ANCOVA design was calculated to assess empathy by the Interpersonal Reactivity Index and the Multifaceted Empathy Test and negative symptoms by the Self-Evaluation of Negative Symptoms. No benefit of oxytocin compared to placebo on empathy was observed, but significant between-group differences favoring oxytocin were found regarding the negative symptoms Diminished emotional range and Avolition. Negative affect and stress were significantly reduced compared to baseline. Mindfulness increased in both groups. Results indicated protocol adherence and retention rate of 91.1%, a drop-out rate of 8.9 % and a completion of 96 % of all sessions by the participants. No severe adverse events or side effects were reported. Our findings indicate proof-of-concept and suggest a potential role of oxytocin on negative symptoms and related variables in SSD in combination with MBGT. Future research should examine the stability of these effects with larger sample sizes.

Differential Effects of Aripiprazole on Electroencephalography-Recorded Gamma-Band Auditory Steady-State Response, Spontaneous Gamma Oscillations and Behavior in a Schizophrenia Rat Model

The available antipsychotics for schizophrenia (SZ) only reduce positive symptoms and do not significantly modify SZ neurobiology. This has raised the question of the robustness and translational value of methods employed during drug development. Electroencephalography (EEG)-based measures like evoked and spontaneous gamma oscillations are considered robust translational biomarkers as they can be recorded in both patients and animal models to probe a key mechanism underlying all SZ symptoms: the excitation/inhibition imbalance mediated by N-methyl-D-aspartate receptor (NMDAr) hypofunction. Understanding the effects of commercialized atypical antipsychotics on such measures could therefore contribute to developing better therapies for SZ. Yet, the effects of such drugs on these EEG readouts are unknown. Here, we studied the effect of the atypical antipsychotic aripiprazole on the gamma-band auditory steady-state response (ASSR), spontaneous gamma oscillations and behavioral features in a SZ rat model induced by the NMDAr antagonist MK-801. Interestingly, we found that aripiprazole could not normalize MK-801-induced abnormalities in ASSR, spontaneous gamma oscillations or social interaction while it still improved MK-801-induced hyperactivity. Suggesting that aripiprazole is unable to normalize electrophysiological features underlying SZ symptoms, our results might explain aripiprazole's inefficacy towards the social interaction deficit in our model but also its limited efficacy against social symptoms in patients.

Efficacy of Using Intermittent Theta Burst Stimulation to Treat Negative Symptoms in Patients with Schizophrenia-A Systematic Review and Meta-Analysis

Negative symptoms in schizophrenia impose a significant burden with limited effective pharmacological treatment options. Recent trials have shown preliminary evidence for the efficacy of using intermittent theta burst stimulation (iTBS) in treating negative symptoms in schizophrenia. We aim to systematically review the current evidence of iTBS in the treatment of the negative symptoms of schizophrenia as an augmentation therapy. The study protocol was developed and registered on Prospero (registration ID: 323381). MEDLINE, EMBASE, Web of Science (Scopus), PsycINFO and Wan Fang databases were searched for sham-controlled, randomized trials of iTBS among patients with schizophrenia. The mean difference in major outcome assessments for negative symptoms was calculated. The quality of evidence was assessed using the Cochrane Risk of Bias Tool (version 1) and the GRADE system. Moreover, 12 studies including a total of 637 participants were included. Compared to sham treatment, the pooled analysis was in favor of iTBS treatment for negative symptoms (mean weight effect size: 0.59, p = 0.03) but not for positive symptoms (mean weight effect size: 0.01, p = 0.91) and depressive symptoms (mean weight effect size: 0.35, p = 0.16). A significant treatment effect was also observed on the iTBS target site left dorsal prefrontal cortex (mean weight effect size: 0.86, p = 0.007) and for stimulation with 80% motor threshold (mean weight effect size: 0.86, p = 0.02). Thus, our synthesized data support iTBS as a potential treatment for negative symptoms among patients with schizophrenia. However, the long-term efficacy and safety issues of iTBS in a larger population have yet to be examined.

The European Portuguese Version of the Brief Negative Symptom Scale

Negative symptoms reflect a currently much-untreated loss of normal functioning and are frequently found in psychotic disorders. We present the first translation of the Brief Negative Symptom Scale (BNSS) to European Portuguese and evaluate its validity in a sample of Portuguese male patients with a psychotic spectrum disorder. The Portuguese BNSS showed excellent internal consistency, high convergent validity (i.e., strong correlation with the PANSS negative factor), and high discriminant validity (i.e., a lack of association with the PANSS positive factor). In sum, the present European Portuguese BNSS has shown to be reliable, thus extending this instrument's clinical availability worldwide.

Effects of a six-month yoga intervention on the immune-inflammatory pathway in antipsychotic-stabilized schizophrenia patients: A randomized controlled trial

BACKGROUND

Schizophrenia is a complex neuropsychiatric disorder for which several etiopathological theories have been proposed, one of the prominent ones being immune dysfunction. Recent studies on yoga as an add-on therapy have shown improvement in negative symptoms, cognition, and quality of life in schizophrenia patients. However, the biological mechanism/s of action of yoga in schizophrenia are not clear. The current study was aimed at exploring the effects of long-term (6 months) add-on yoga therapy on the immune inflammatory pathway in schizophrenia patients.

METHODS

Sixty schizophrenia patients were randomized to add-on yoga therapy (YT=30) and treatment-as-usual (TAU=30) groups of which 21 patients in YT and 20 in TAU group completed the study. Blood samples and clinical assessments were obtained at baseline and at the end of 6 months. The plasma levels of nine cytokines (IL-2, IL-4, IL-5, IL-10, IL-12(p70), IL-13, GM-CSF, IFN-γ, and TNF-α) were quantified using multiplex suspension array. The clinical assessments included SAPS, SANS, BPRS, PSS, CGI, SOFS and WHOQUOL-BREF.

RESULTS

Patients in the yoga group showed significant reductions in plasma TNF-α (Z = 2.99, p = 0.003) and IL-5 levels (Z = 2.20, p = 0.03) and greater clinical improvements in SAPS, SANS, PSS, and SOFS scores as compared to TAU group. Further, plasma TNF-α levels exhibited a positive correlation with negative symptoms (r_s =0.45, p = 0.02) and socio-occupational functioning (r_s =0.61, p = 0.002) in the YT group.

CONCLUSIONS

The findings of the study suggest that improvements in schizophrenia psychopathology with yoga interventions are associated with immuno-modulatory effects.

Dopamine Dynamics and Neurobiology of Non-Response to Antipsychotics, Relevance for Treatment Resistant Schizophrenia: A Systematic Review and Critical Appraisal

Treatment resistant schizophrenia (TRS) is characterized by a lack of, or suboptimal response to, antipsychotic agents. The biological underpinnings of this clinical condition are still scarcely understood. Since all antipsychotics block dopamine D2 receptors (D2R), dopamine-related mechanisms should be considered the main candidates in the neurobiology of antipsychotic non-response, although other neurotransmitter systems play a role. The aims of this review are: (i) to recapitulate and critically appraise the relevant literature on dopamine-related mechanisms of TRS; (ii) to discuss the methodological limitations of the studies so far conducted and delineate a theoretical framework on dopamine mechanisms of TRS; and (iii) to highlight future perspectives of research and unmet needs. Dopamine-related neurobiological mechanisms of TRS may be multiple and putatively subdivided into three biological points: (1) D2R-related, including increased D2R levels; increased density of D2Rs in the high-affinity state; aberrant D2R dimer or heteromer formation; imbalance between D2R short and long variants; extrastriatal D2Rs; (2) presynaptic dopamine, including low or normal dopamine synthesis and/or release compared to responder patients; and (3) exaggerated postsynaptic D2R-mediated neurotransmission. Future points to be addressed are: (i) a more neurobiologically-oriented phenotypic categorization of TRS; (ii) implementation of neurobiological studies by directly comparing treatment resistant vs. treatment responder patients; (iii) development of a reliable animal model of non-response to antipsychotics.

Latent Inhibition in Schizophrenia and Schizotypy

Background

The Salience Hypothesis posits that aberrations in the assignment of salience culminate in hallucinations and unusual beliefs, the "positive symptoms" of schizophrenia. Evidence for this comes from studies on latent inhibition (LI), referring to the phenomenon that prior exposure to a stimulus impedes learning about the relationship between that stimulus and an outcome.

Design

This article reviewed all published studies examining the relationship between LI and both schizophrenia and schizotypy.

Results

Contemporary literature suggests that LI is attenuated in both people with schizophrenia and those loading highly on measures of schizotypy, the multidimensional derivative of schizophrenia. This suggests that these individuals assign greater salience to stimuli than healthy controls and people scoring low on measures of schizotypy, respectively. However, several confounds limit these conclusions. Studies on people with schizophrenia are limited by the confounding effects of psychotropic medications, idiosyncratic parsing of samples, variation in dependent variables, and lack of statistical power. Moreover, LI paradigms are limited by the confounding effects of learned irrelevance, conditioned inhibition, negative priming, and novel pop-out effects.

Conclusions

This review concludes with the recommendation that researchers develop novel paradigms that overcome these limitations to evaluate the predictions of the Salience Hypothesis.

Evaluation of the acute oral toxicity and antipsychotic activity of a dual inhibitor of PDE1B and PDE10A in rat model of schizophrenia

Phosphodiesterase 1B (PDE1B) and PDE10A are dual-specificity PDEs that hydrolyse both cyclic adenosine monophosphate and cyclic guanosine monophosphate, and are highly expressed in the striatum. Several reports have suggested that PDE10A inhibitors may present a promising approach for the treatment of positive symptoms of schizophrenia, whereas PDE1B inhibitors may present a novel mechanism to modulate cognitive deficits. Previously, we have reported a novel dual inhibitor of PDE1B and PDE10A, compound 2 [(3-fluorophenyl)(2-methyl-2,3-dihydro-4H-benzo[b][1,4]oxazin-4-yl)methanone] which has shown inhibitory activity for human recombinant PDE1B and PDE10A in vitro. In the present study, the safety profile of compound 2 has been evaluated in rats in the acute oral toxicity study, as well as; the antipsychotic-like effects in the rat model of schizophrenia. Compound 2 was tolerated up to 1 g/kg when administered at a single oral dose. Additionally, compound 2 has strongly suppressed ketamine-induced hyperlocomotion, which presented a model for the positive symptoms of schizophrenia. It has also shown an ability to attenuate social isolation induced by chronic administration of ketamine and enhanced recognition memory of rats ​in the novel object recognition test. Altogether, our results suggest that compound 2 represents a promising therapy for the treatment of the three symptomatic domains of schizophrenia.

The differential associations of positive and negative symptoms with suicidality

BACKGROUND

Suicide is one of the leading causes of death in people with schizophrenia. Identifying risk factors for suicide in schizophrenia is therefore an important clinical and research priority.

METHOD

A cross-sectional secondary analysis was conducted on the DNA Polymorphisms in Mental Illness Study (DPIM) data. Suicidality data was extracted, and the number of positive and negative symptoms were established for a total of 1494 participants. Logistic and negative binomial regression analyses were conducted to assess for associations between positive or negative symptoms and suicidal ideation, attempt, or number of attempts, whilst adjusting for potential confounders.

RESULTS

Negative symptoms were associated with a reduction in the risk of suicidal ideation (odds ratio [OR]: 0.83; 95 % CI: 0.75-0.91) and suicide attempt (OR: 0.79; 95 % CI: 0.71-0.88) after adjusting for age and sex. Positive symptoms were associated with an increased risk of suicidal ideation (OR: 1.06; 95 % CI: 1.03-1.09), suicide attempt (OR: 1.04; 95 % CI: 1.00-1.07) and number of suicide attempts (incidence rate ratio [IRR]: 1.05; 95 % CI: 1.01-1.08). Further adjusting for depressive symptoms slightly increased the magnitude of associations with negative symptoms but attenuated associations between positive symptoms and suicidality to the null.

CONCLUSIONS

Negative symptoms are associated with a reduced risk of suicidality, whilst positive symptoms are associated with an increased risk of suicidality. Depressive symptoms may confound or mediate these associations.

Oxidative Stress and Emergence of Psychosis

Treatment and prevention strategies for schizophrenia require knowledge about the mechanisms involved in the psychotic transition. Increasing evidence suggests a redox imbalance in schizophrenia patients. This narrative review presents an overview of the scientific literature regarding blood oxidative stress markers’ evolution in the early stages of psychosis and chronic patients. Studies investigating peripheral levels of oxidative stress in schizophrenia patients, first episode of psychosis or UHR individuals were considered. A total of 76 peer-reviewed articles published from 1991 to 2022 on PubMed and EMBASE were included. Schizophrenia patients present with increased levels of oxidative damage to lipids in the blood, and decreased levels of non-enzymatic antioxidants. Genetic studies provide evidence for altered antioxidant functions in patients. Antioxidant blood levels are decreased before psychosis onset and blood levels of oxidative stress correlate with symptoms severity in patients. Finally, adjunct treatment of antipsychotics with the antioxidant N-acetyl cysteine appears to be effective in schizophrenia patients. Further studies are required to assess its efficacy as a prevention strategy. Redox imbalance might contribute to the pathophysiology of emerging psychosis and could serve as a therapeutic target for preventive or adjunctive therapies, as well as biomarkers of disease progression.

Spatial and chronic differences in neural activity in medicated and unmedicated schizophrenia patients

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The medicated schizophrenia group yielded concordant activity among three right lateralized frontal clusters and a left lateralized parietal cluster.

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The unmedicated schizophrenia group yielded concordant activity among right lateralized frontal-parietal regions.

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A neural compensatory mechanism in schizophrenia.

A major caveat with investigations on schizophrenic patients is the difficulty to control for medication usage across samples as disease-related neural differences may be confounded by medication usage. Following a thorough literature search (632 records identified), we included 37 studies with a total of 740 medicated schizophrenia patients and 367 unmedicated schizophrenia patients. Here, we perform several meta-analyses to assess the neurofunctional differences between medicated and unmedicated schizophrenic patients across fMRI studies to determine systematic regions associated with medication usage. Several clusters identified by the meta-analysis on the medicated group include three right lateralized frontal clusters and a left lateralized parietal cluster, whereas the unmedicated group yielded concordant activity among right lateralized frontal-parietal regions. We further explored the prevalence of activity within these regions across illness duration and task type. These findings suggest a neural compensatory mechanism across these regions both spatially and chronically, offering new insight into the spatial and temporal dynamic neural differences among medicated and unmedicated schizophrenia patients.

The Impact of Electroconvulsive Therapy on Negative Symptoms in Schizophrenia and Their Association with Clinical Outcomes

OBJECTIVE

The treatment efficacy of electroconvulsive therapy (ECT) for negative symptoms amongst patients with schizophrenia remains unclear. In this study, we aim to examine the effects of ECT on negative symptoms in schizophrenia and their association with other clinical outcomes, including cognition and function.

METHODS

This is a retrospective data analysis of patients with schizophrenia/schizoaffective disorder treated with ECT at the Institute of Mental Health (IMH), Singapore, between January 2016 and December 2019. Clinical outcomes were assessed by the Brief Psychiatric Rating Scale (BPRS), the Montreal Cognitive Assessment (MoCA), and Global Assessment of Function (GAF). Changes in scores were compared with repeated measures analysis of variance. Sequential structural modelling was utilized to examine the pathway relationships between changes in negative symptoms, global functioning, and cognition functioning after ECT.

RESULTS

A total of 340 patients were analysed. Hence, 196 (57.6%), 53 (15.5%), and 91 (26.7%) showed improvements, no change, and deterioration in negative symptoms, respectively. ECT-induced improvement of negative symptoms was significantly associated with improvement of global functioning (direct effect correlation coefficient (r): -0.496; se: 0.152; p = 0.001) and cognition function (indirect effect r: -0.077; se: 0.037; p = 0.035). Moreover, having capacity to consent, more severe baseline negative symptoms, lithium prescription, and an indirect effect of voluntary admission status via consent capacity predicted ECT associated negative symptoms improvement.

CONCLUSION

ECT is generally associated with improvements of negative symptoms in people with schizophrenia, which correlate with improvements of overall function. Possible novel clinical predictors of negative symptom improvement have been identified and will require further research and validation.

Electrophysiological measures from human iPSC-derived neurons are associated with schizophrenia clinical status and predict individual cognitive performance

Neurons derived from human induced pluripotent stem cells (hiPSCs) have been used to model basic cellular aspects of neuropsychiatric disorders, but the relationship between the emergent phenotypes and the clinical characteristics of donor individuals has been unclear. We analyzed RNA expression and indices of cellular function in hiPSC-derived neural progenitors and cortical neurons generated from 13 individuals with high polygenic risk scores (PRSs) for schizophrenia (SCZ) and a clinical diagnosis of SCZ, along with 15 neurotypical individuals with low PRS. We identified electrophysiological measures in the patient-derived neurons that implicated altered Na+ channel function, action potential interspike interval, and gamma-aminobutyric acid-ergic neurotransmission. Importantly, electrophysiological measures predicted cardinal clinical and cognitive features found in these SCZ patients. The identification of basic neuronal physiological properties related to core clinical characteristics of illness is a potentially critical step in generating leads for novel therapeutics.

Primary and Secondary Negative Symptoms in Schizophrenia

The negative symptoms of schizophrenia include volitional (motivational) impairment manifesting as avolition, anhedonia, social withdrawal, and emotional disorders such as alogia and affective flattening. Negative symptoms worsen patients' quality of life and functioning. From the diagnostic point of view, it is important to differentiate between primary negative symptoms, which are regarded as an integral dimension of schizophrenia, and secondary negative symptoms occurring as a result of positive symptoms, comorbid depression, side effects of antipsychotics, substance abuse, or social isolation. If secondary negative symptoms overlap with primary negative symptoms, it can create a false clinical impression of worsening deficit symptoms and disease progression, which leads to the choice of incorrect therapeutic strategy with excessive dopamine blocker loading. Different longitudinal trajectories of primary and secondary negative symptoms in different schizophrenia stages are proposed as an important additional discriminating factor. This review and position paper focuses primarily on clinical aspects of negative symptoms in schizophrenia, their definition, phenomenology, factor structure, and classification. It covers the historical and modern concepts of the paradigm of positive and negative symptoms in schizophrenia, as well as a detailed comparison of the assessment tools and psychometric tests used for the evaluation of negative symptoms.

Development of novel antipsychotic agents by inhibiting dopamine transporter – in silico approach

Various in silico methods were employed for the development of antipsychotic agents by dopamine transporter inhibition.

Rationale and study design of a trial to assess rTMS add-on value for the amelioration of negative symptoms of schizophrenia (RADOVAN)

Background

Methods

Discussion

Trial registration number

Data dissemination

The Relationship Between the Recognition of Basic Emotions and Negative Symptoms in Individuals With Schizophrenia Spectrum Disorders - An Exploratory Study

Current research suggests that emotion recognition is impaired in individuals affected by schizophrenia spectrum disorders (SSD). However, the specific impact of negative symptoms on the ability to recognize single basic emotions has not yet been explored sufficiently and is the aim of the present study. A sample of N = 66 individuals diagnosed with SSD was recruited at the Charité - Universitätsmedizin Berlin. In a first step, correlation analyses were conducted between seven different negative symptom subdomains of the Positive and Negative Syndrome Scale (PANSS) and the accuracy and latency in recognizing the six basic emotions (anger, disgust, fear, happiness, sadness, surprise) using the Emotion Recognition Task (ERT) of the Cambridge Neuropsychological Test Automated Battery (CANTAB). The significant correlations were subjected to linear regression models that controlled for the significant covariates diagnoses, age, sex, and education. Results revealed that in individuals with SSD the negative symptom domain of blunted affect significantly predicted the accuracy of emotion recognition performance (p < 0.05), particularly, when recognizing happiness (p < 0.05). Additionally, we found that stereotyped thinking also predicted the performance of emotion recognition, especially the response latency (p < 0.05) and difficulty in abstract thinking predicted the recognition of fear (p < 0.05). However, the nominal significances did not withstand correction for multiple tests and therefore need to be followed up in further studies with a larger sample.

Defining negative symptoms remission in schizophrenia using the Brief Negative Symptom Scale

INTRODUCTION

This study aimed to propose criteria for negative symptoms remission (NSR) in schizophrenia using the Brief Negative Symptom Scale (BNSS).

MATERIAL AND METHODS

274 participants were assessed on the Positive and Negative Syndrome Scale (PANSS), BNSS and Social and Occupational Functioning Assessment Scale (SOFAS). Two criteria for NSR on the BNSS were proposed - NSR based on the BNSS domains scores (NSR_{BNSS_DOMAINS}) and NSR based on 5 key items of the BNSS (NSR_{BNSS_5ITEMS})_. A SOFAS score of 61 and above was considered as functional remission (FR). Logistic regressions were run to examine the association between FR and NSR. Receiver operating characteristic (ROC) curve analysis was performed for the NSR criteria on FR. Kappa agreement statistic was used to evaluate the agreement between the two NSR criteria.

RESULTS

Eighty-nine (32.5%) participants fulfilled NSR_{BNSS_DOMAINS} criterion whereas 70 (25.6%) participants fulfilled NSR_{BNSS_5ITEMS} criterion. The two NSR criteria had substantial agreement (Kappa statistic=0.797) with each other. Sixty-one (25.3%) participants were in FR. FR was significantly associated with NSR, irrespective of the criterion used. To predict FR, the Area Under the Curve for NSR_{BNSS_DOMAINS} and NSR_{BNSS_5ITEMS} were 0.761 (CI: 0.696-0.826, p<0.001) and 0.723 (CI: 0.656-0.790, p<0.001), respectively. Hence, both NSR criteria demonstrated a fair ability to discriminate between functional remitters and non-remitters.

CONCLUSIONS

Depending on the setting and needs, clinicians and researchers might employ either the full BNSS or an abbreviated 5-item BNSS scale to identify NSR in schizophrenia. More research is needed to further examine the validity of these criteria in schizophrenia.

Motivational Processes Influencing Mental Health Among Winter Sports Athletes in China

This study examined the association between motivational processes, psychological distress (depression, anxiety, and stress), and burnout among winter sports athletes within the Hierarchical Model of Intrinsic and Extrinsic Motivation (HMIEM). A total of 685 winter sport athletes participated in this study (377 males, 308 females, age range 18-25 years), from three sport universities across nine winter sports. They completed five psychometric inventories related to motivational factors and mental disorders. Overall, a task-oriented climate showed a positive association with basic psychological needs, eliciting a positive pathway to autonomous and controlled motivation. In contrast, an ego-oriented climate showed a negative association with basic psychological needs, eliciting a negative pathway to amotivation. Autonomous and controlled motivation were negatively associated with symptoms of psychological distress and burnout, while amotivation was positively associated with symptoms of psychological distress and burnout. These findings highlight the complex relationships between various motivational factors and mental health disorders among winter sport athletes, and support the essential requirement for adding mental health factors to the outcomes of the HMIEM sequence.

"Predictors of Negative Symptom Domains in Outpatients with Schizophrenia: A Cross-Sectional Study"

"Background: Current research suggests that negative symptoms may not be a unitary construct. Factor analytic studies typically found evidence for a two-factor solution of the negative symptom domain: the expressive and the volitional deficit. This study aimed to investigate whether the two-factor solution of negative symptoms is supported across different instruments of evaluation: PANSS and NSA-16 in outpatients with schizophrenia and to explore the relationship between these domains and sociodemographic, clinical, and metabolic outcomes, routinely assessed in daily practice.Another aim was to determine clinical predictors of negative symptoms domains among these variables. Materials and methods: 107 patients with schizophrenia were included in this cross-sectional study. The Principal Component Analysis was used to identify negative symptom domains and Spearman's rank correlation coefficient and multiple regression analyses were used to assess the relationship between the negative symptom domains and clinical variables. Results: PCA indicated a two-component solution explaining 85.2% of the variance for the NSA-16 subscales, reflecting an expressive deficit and an experiential deficit component. Age of onset of the disease and the cognitive deficit were significant predictors of the expressive deficit , body mass index and the number of admissions in the hospital for the experiential deficit. Conclusions: The current findings indicate that the expressive deficit and the experiential deficit should be considered as distinct domains of the psychopathology and should be rated separately"

Enhancing stress reactivity and wellbeing in early schizophrenia: A randomized controlled trial of Integrated Coping Awareness Therapy (I-CAT)

Individuals with schizophrenia spectrum disorders (SSD) are at heightened risk for exposure to stressful life events which can lead to increased sensitivity to stress and a dysregulated stress response, which are in turn associated with poor long-term functioning. Stress reactivity is thus a promising treatment target in the early stages of SSD. Integrated-Coping Awareness Therapy (I-CAT) is a manualized intervention integrating mindfulness and positive psychology to target a dysregulated stress response in SSD. The current study is a preliminary randomized-controlled trial (RCT) comparing I-CAT (n = 18) with treatment as usual (TAU; n = 18) in individuals in the early stages of SSD. I-CAT was hypothesized to be more effective than TAU on primary outcomes: increasing positive emotions, decreasing negative emotions, reducing stress, and improving functioning and quality of life; and secondary outcomes: reducing symptoms, increasing mindfulness, and improving overall well-being. Excellent therapy attendance rates, low study attrition, and positive participant feedback demonstrated that I-CAT was a feasible and well-tolerated psychosocial intervention. Results suggest I-CAT led to greater reduction in symptoms (i.e., overall, negative, and disorganized symptoms), increased observational mindfulness, increased endorsement of a sense of purpose in life, and preservation of work abilities and school social functioning compared with TAU. Future work should replicate and extend these findings in a larger-scale RCT.

Comparative Efficacy, Safety and Tolerability of Olanzapine and Blonanserin in Patients with Schizophrenia: A Parallel Group Study

Background

The antipsychotic olanzapine is a first-line drug in the treatment of schizophrenia while blonanserin is indicated in resistant cases of schizophrenia when the first line antipsychotics have failed. There are very limited studies available world-wide as well as in India that compare blonanserin with other antipsychotics in the setting of schizophrenia.

Aims

To study the efficacy, safety and tolerability of olanzapine and blonanserin in Schizophrenia. Settings and Design: The study was a prospective, observational, parallel group study done on schizophrenia patients aged between 18-50 years of both sexes at an outpatient Department of Psychiatry, in a tertiary medical college. The study was conducted from February 2015 to October 2016, with follow ups at weeks 4, 8 and 12.

Materials and Methods

The efficacy parameters were measured by the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression (CGI) rating. The safety parameters included the vital signs, haematological profile, lipid profile, blood sugar monitoring. Adverse drug reactions and compliance to therapy was observed through-out the study period. Appropriate statistical tests were applied to detect any significant within and between group differences using Microsoft Excel 2007 and SPSS version 17.

Results

There was significant decrease in the mean total score on the BPRS and CGI-S in the blonanserin arm at the 2nd and last follow up visit (p value < 0.001). Compliance was good in both groups (≤ 20% missed pills). Overall, 77 treatment-emergent adverse events were present from 56 patients. Twenty three subjects of the blonanserin arm and 33 subjects in the olanzapine arm at least experienced one adverse event (p = 0.006), metabolic adverse effects were more common with olanzapine, whereas insomnia, headache and somnolence were more often seen with blonanserin.

Conclusions

In the present study, blonanserin provided significantly better outcomes than olanzapine with respect to BPRS, CGI-S scores.

G-estimation of causal pathways in vocational rehabilitation for adults with psychotic disorders - a secondary analysis of a randomized trial

BACKGROUND

Vocational rehabilitation (VR) has increasingly become an important intervention targeting poor occupational functioning in schizophrenia. The Norwegian Job Management Program (JUMP), sought to enhance occupational outcomes by augmenting VR with either cognitive behavioral therapy (CBT) techniques aiming to improve psychotic symptoms or cognitive remediation (CR) aiming to improve cognition. CBT is standard treatment in schizophrenia, but recent meta-analyses question the effect of CBT on negative psychotic symptoms. It is of interest to study the causal role of psychotic symptoms and cognitive functioning on occupational functioning.

METHODS

Data from the JUMP VR - program, was reanalyzed with a causal inference method to assess the causal effects of reduced symptoms / improved neurocognitive functioning on occupational functioning measured by number of working hours per week. Participants (N = 131) had been randomized to either VR + CBT (N = 68) or VR + CR (N = 63). Large improvements in number of working hours were demonstrated in both intervention groups (nonsignificant group difference). G-estimation was used to assess the strength and nature of the causal effects, adjusted for time-varying confounding and selection - bias from loss to follow-up.

RESULTS

Significant causal effects of reduction in each of four dimensions of symptoms and improved neurocognition respectively, on number of working hours were found (separate models). The effect of negative symptoms was the strongest and increased in magnitude during the whole observation period, while the effect of two other symptoms and neurocognition was constant. Adjusted for confounding (including potential feedback), the causal effect of a hypothetical change in negative symptoms equal to the average improvement in the CBT group corresponded to an increase in working hours of 3.2 h per week (95% CI: 1.11, 5.35).

CONCLUSION

High performance of g-estimation in a small psychiatric data set with few repeated measures and time-varying confounding and effects, was demonstrated. Augmented vocational rehabilitation showed causal effects of intervention targets with the strongest and increasing effect from negative symptoms on number of working hours. Combination of therapy and activation (indirect and direct approach) might explain improvement in both cognition and negative symptoms, and shed some light on effective ingredients for improved treatment of negative symptoms.

Selective serotonin reuptake inhibitors and risk reduction for cardiovascular disease in patients with schizophrenia: A controversial but promising approach

Patients with schizophrenia (SCZ) are at high risk of cardiovascular disease (CVD) due to an inherited predisposition, a sedentary life style and the use of antipsychotic medications. Several approaches have been taken to minimize this risk but results continue to be unsatisfactory. A potential alternative is prescribing selective serotonin reuptake inhibitors (SSRIs). SSRIs decrease platelet aggregation and reduce the risk of coronary heart disease in patients with depression. We therefore aim to investigate whether there is evidence that supports the use of SSRIs to reduce the risk for CVD in SCZ. A review of the literature revealed five published reports relating to the impact of SSRIs on CV risk in SCZ. Three trials assessed the influence on metabolic parameters of fluvoxamine when combined with clozapine. Two of those studies found improvements with fluvoxamine. Of the other two reports, one indicates SSRIs as a group caused minimal but statistically significant increments in total cholesterol, low-density lipoprotein and triglyceride. The second report suggests that when SSRIs are combined with antipsychotics, the metabolic impact depends on the antipsychotic prescribed. While there are promising results, no conclusions can be made currently on whether SSRIs increase or decrease CV risk in SCZ. Further studies are needed to resolve this matter.

Electroconvulsive therapy for negative symptoms in schizophrenia: a literature review from 2000 to 2021

Negative symptoms in schizophrenia remain a clinical challenge with small effect sizes and evidence for pharmacological or psychotherapeutic treatment approaches. Studies suggest that electroconvulsive therapy (ECT) holds some promise as a treatment option of often persistent negative symptoms with clinically meaningful effects. This review summarizes the existing evidence on the efficacy of ECT on negative symptoms in patients with schizophrenia. Thirty-five publications were included in this literature review comprising 21 studies, two meta-analyses, eight reviews and four case reports. Conclusions should be interpreted cautiously, given the small number and methodological shortcomings of the included publications with a variation of study designs and missing standardized protocols. Implications for future research and practice are critically discussed. Recommendations are given to provide more evidence that will meet the clinical challenge of reducing the negative symptoms in schizophrenia. Study designs that focus explicitly on negative symptoms and assess patients over longer follow up periods could be helpful. Future research should include control groups, and possibly establish international multicentered studies to get a sufficient study population. Findings suggest that patients with schizophrenia resistant to pharmacological treatment might benefit from ECT. A risk and benefit assessment speaks in favour of the ECT treatment. Future practice of ECT should include a combination treatment with antipsychotics. Whereas the use of anaesthetics and electrode placement does not seem to play a role, the recommendation regarding frequency of ECT treatments is currently three times a week, For the assessment of negative symptoms the assessment tool should be chosen carefully.

Atypical Antipsychotic Lumateperone Effects on the Adrenal Gland With Possible Beneficial Effect of Quercetin Co-administration

Schizophrenia remains one of the most chronic and highly disabling mental disorders. Lumateperone is a recent FDA-approved atypical antipsychotic drug for the treatment of schizophrenia. However, the internal FDA pathologist raised concerns regarding pigment deposition associated with degeneration in different tissue in animal studies with lumateperone treatment. The adrenal gland may be implicated in lumateperone side effects, and quercetin may have the ability to fulfill this treatment gap. To prove this hypothesis, 40 male guinea pigs were used and divided into four groups; control, quercetin-treated, lumateperone-treated, and quercetin/lumateperone cotreated orally for 28 consecutive days. Behavioral forced swim (FST) and open field (OF) tests were done at the end of treatment. Retro-orbital blood samples were taken to assess hormones: adrenocorticotropic hormone (ACTH), cortisol, dehydroepiandrosterone acetate (DHEA), and aldosterone, along with an assessment of oxidative stress parameters: malondialdehyde (MDA), glutathione (GSH), and superoxide dismutase (SOD). Adrenal glands were extracted for histopathological assessment with H&E, Mallory trichome staining, immunostaining, and electron microscopy studies. Lumateperone-treated group showed a significant reduction in the activity in FST and OF with histopathological deterioration in adrenal secretory function and structure and increased expression of interleukin-6 (IL-6), CASPASE-3, collagen deposition, and decreased proliferating cell nuclear antigen (PCNA). Cytoplasmic vacuolation, pyknosis of the nuclei, increase in the lysosome, lipofuscin pigment, and cellular infiltration with diminishing in the number of secretory granules could all be observed in lumateperone-treated group. Coadministration of quercetin and lumateperone showed improvement of the previously deteriorated parameters. Quercetin had a prophylactic effect against lumateperone depressive-like effect on animal behavior and its possible adrenal damage.

Graphical Abstract

The Augmentation Effect of N-Acetyl Cysteine Antioxidant on Superoxide Dismutase Levels in Schizophrenic Patients Treated with Risperidone

Background: Schizophrenia affects approximately 1% of the population and in Indonesia the prevalence is about 400.000 people or as many as 1.7 per 10000 individuals of the population. Schizophrenia is characterized by positive symptoms, negative symptoms and also cognitive, aggressive, and affective symptoms, where negative symptoms reflect loss of function. One important factor that plays a role in the pathophysiology of schizophrenia is the excessive production of free radical substances and the failure of the anti-oxidant defense process. The aim of this study is to see how levels of superoxide dismutase change after N-acetylcystein augmentation in schizophrenic patients treated with risperidone. This study is a pre-post experimental test design, where schizophrenic patients meet inclusion and exclusion criteria. At baseline, and after 8 weeks of N-acetyl cysteine administration, patients were assessed at each of the time points using PANSS, and SOD was measured in blood at both time points.       The average negative PANSS score in the Risperidone + NAC baseline group was 29.93 (±1.83); in the Risperidone group was 29.83 (±1.19)  (p = 0.87). The average negative PANSS score at the end of week 8 was statistically significantly different (p = 0.001) in the Risperidone + NAC group (17.40 ±1.84) and in the Riseridone group (21.00±0.74). The average baseline SOD levels in the Risperidone + NAC group were 63.57 (±22.44), and in the Risperidone group was 85.79 (±101.05). SOD levels at week 8 in the Risperidone + NAC group were 71.72 (±31.20) and in the Risperidone group 128.27 (±117.67). ∆ SOD in the Risperidone + NAC group was 8.15 (19.54) and ∆ SOD in the Risperidone group was 42.48± (54.30).  p value of 0.028Research data shows that NAC augmentation can improve the negative symptoms of schizophrenia through reducing SOD levels in the blood.

Adjunctive yoga training for persons with schizophrenia: who benefits?

OBJECTIVE

The aim of this study was to identify factors associated with acceptability and efficacy of yoga training (YT) for improving cognitive dysfunction in individuals with schizophrenia (SZ).

METHODS

We analysed data from two published clinical trials of YT for cognitive dysfunction among Indians with SZ: (1) a 21-day randomised controlled trial (RCT, N = 286), 3 and 6 months follow-up and (2) a 21-day open trial (n = 62). Multivariate analyses were conducted to examine the association of baseline characteristics (age, sex, socio-economic status, educational status, duration, and severity of illness) with improvement in cognition (i.e. attention and face memory) following YT. Factors associated with acceptability were identified by comparing baseline demographic variables between screened and enrolled participants as well as completers versus non-completers.

RESULTS

Enrolled participants were younger than screened persons who declined participation (t = 2.952, p = 0.003). No other characteristics were associated with study enrollment or completion. Regarding efficacy, schooling duration was nominally associated with greater and sustained cognitive improvement on a measure of facial memory. No other baseline characteristics were associated with efficacy of YT in the open trial, the RCT, or the combined samples (n = 148).

CONCLUSIONS

YT is acceptable even among younger individuals with SZ. It also enhances specific cognitive functions, regardless of individual differences in selected psychosocial characteristics. Thus, yoga could be incorporated as adjunctive therapy for patients with SZ. Importantly, our results suggest cognitive dysfunction is remediable in persons with SZ across the age spectrum.

Defining negative symptoms remission in schizophrenia using the Brief Negative Symptom Scale

INTRODUCTION

This study aimed to propose criteria for negative symptoms remission (NSR) in schizophrenia using the Brief Negative Symptom Scale (BNSS).

MATERIAL AND METHODS

274 participants were assessed on the Positive and Negative Syndrome Scale (PANSS), BNSS and Social and Occupational Functioning Assessment Scale (SOFAS). Two criteria for NSR on the BNSS were proposed - NSR based on the BNSS domains scores (NSRBNSS_DOMAINS) and NSR based on 5 key items of the BNSS (NSRBNSS_5ITEMS). A SOFAS score of 61 and above was considered as functional remission (FR). Logistic regressions were run to examine the association between FR and NSR. Receiver operating characteristic (ROC) curve analysis was performed for the NSR criteria on FR. Kappa agreement statistic was used to evaluate the agreement between the two NSR criteria.

RESULTS

Eighty-nine (32.5%) participants fulfilled NSRBNSS_DOMAINS criterion whereas 70 (25.6%) participants fulfilled NSRBNSS_5ITEMS criterion. The two NSR criteria had substantial agreement (Kappa statistic=0.797) with each other. Sixty-one (25.3%) participants were in FR. FR was significantly associated with NSR, irrespective of the criterion used. To predict FR, the Area Under the Curve for NSRBNSS_DOMAINS and NSRBNSS_5ITEMS were 0.761 (CI: 0.696-0.826, p<0.001) and 0.723 (CI: 0.656-0.790, p<0.001), respectively. Hence, both NSR criteria demonstrated a fair ability to discriminate between functional remitters and non-remitters.

CONCLUSIONS

Depending on the setting and needs, clinicians and researchers might employ either the full BNSS or an abbreviated 5-item BNSS scale to identify NSR in schizophrenia. More research is needed to further examine the validity of these criteria in schizophrenia.

Phosphodiesterase as a Target for Cognition Enhancement in Schizophrenia

Schizophrenia is a severe mental disorder that affects more than 1% of the population worldwide. Dopamine system dysfunction and alterations in glutamatergic neurotransmission are strongly implicated in the aetiology of schizophrenia. To date, antipsychotic drugs are the only available treatment for the symptoms of schizophrenia. These medications, which act as D2-receptor antagonist, adequately address the positive symptoms of the disease, but they fail to improve the negative symptoms and cognitive impairment. In schizophrenia, cognitive impairment is a core feature of the disorder. Therefore, the treatment of cognitive impairment and the other symptoms related to schizophrenia remains a significant unmet medical need. Currently, phosphodiesterases (PDEs) are considered the best drug target for the treatment of schizophrenia since many PDE subfamilies are abundant in the brain regions that are relevant to cognition. Thus, this review aims to illustrate the mechanism of PDEs in treating the symptoms of schizophrenia and summarises the encouraging results of PDE inhibitors as anti-schizophrenic drugs in preclinical and clinical studies.

Dynamic functional connectivity and its anatomical substrate reveal treatment outcome in first-episode drug-naïve schizophrenia

Convergent evidence has suggested a significant effect of antipsychotic exposure on brain structure and function in patients with schizophrenia, yet the characteristics of favorable treatment outcome remains largely unknown. In this work, we aimed to examine how large-scale brain networks are modulated by antipsychotic treatment, and whether the longitudinal changes could track the improvements of psychopathologic scores. Thirty-four patients with first-episode drug-naïve schizophrenia and 28 matched healthy controls were recruited at baseline from Shanghai Mental Health Center. After 8 weeks of antipsychotic treatment, 24 patients were re-scanned. Through a systematical dynamic functional connectivity (dFC) analysis, we investigated the schizophrenia-related intrinsic alterations of dFC at baseline, followed by a longitudinal study to examine the influence of antipsychotic treatment on these abnormalities by comparing patients at baseline and follow-up. A structural connectivity (SC) association analysis was further carried out to investigate longitudinal anatomical changes that underpin the alterations of dFC. We found a significant symptomatic improvement-related increase in the occurrence of a dFC state characterized by stronger inter-network integration. Furthermore, symptom reduction was correlated with increased FC variability in a unique connectomic signature, particularly in the connections within the default mode network and between the auditory, cognitive control, and cerebellar network to other networks. Additionally, we observed that the SC between the superior frontal gyrus and medial prefrontal cortex was decreased after treatment, suggesting a relaxation of normal constraints on dFC. Taken together, these findings provide new evidence to extend the dysconnectivity hypothesis in schizophrenia from static to dynamic brain network. Moreover, our identified neuroimaging markers tied to the neurobiology of schizophrenia could be used as potential indicators in predicting the treatment outcome of antipsychotics.

N-acetylcysteine as a new prominent approach for treating psychiatric disorders

N-acetylcysteine (NAC) is a well-known and safe mucolytic agent, also used in patients with paracetamol overdose. In addition to these effects, recent preclinical and clinical studies have shown that NAC exerts beneficial effects on different psychiatric disorders. Many potential mechanisms have been proposed to underlie the therapeutic effects of NAC, including the regulation of several neurotransmitters, oxidative homeostasis, and inflammatory mediators. In this paper, we summarize the current knowledge on the ability of NAC to ameliorate symptoms and neuropathologies related to different psychiatric disorders, including attention deficit hyperactivity disorder, anxiety, bipolar disorder, depression, obsessive-compulsive disorder, obsessive-compulsive-related disorder, posttraumatic stress disorder, and schizophrenia. Although preclinical studies have shown a positive effect of NAC on animal models of psychiatric disorders, the clinical efficacy of NAC is not fully established. NAC remains a strong candidate for adjunct treatment for many psychiatric disorders, but additional preclinical and clinical studies are needed.

Add on yoga treatment for negative symptoms of schizophrenia: A multi-centric, randomized controlled trial

The efficacy of antipsychotic medications in the treatment of negative symptoms of schizophrenia is modest at best. Preliminary studies suggest the beneficial effects of add on Yoga, a traditional Indian practice, in the treatment of schizophrenia. Hence, in this study, we examined the efficacy of yoga as an add-on treatment for negative symptoms of schizophrenia in a randomized, wait-list controlled design from two clinical institutes in south India. 89 patients (age - 34.20 ± 8.06 years; education - 14.22 ± 2.69 years; 28 females) were randomized into the add-on yoga or treatment as usual (TAU - wait-list control) group. Patients had a mean illness duration of 10.97 ± 7.24 years with an age at onset of 23.34 ± 5.81 years. Central block randomization was followed to ensure concealed allocation. Participants randomized to the yoga treatment group attended 12 supervised yoga training sessions over two weeks and practiced yoga sessions at home for the subsequent 10 weeks. 64 patients completed the trial. An intent to treat analysis was conducted with 89 participants using a linear mixed model. Improvement in negative symptoms was our primary outcome measure. The two groups were matched on demographic variables and baseline psychopathology severity. Participants in the add-on yoga group had significantly greater improvement in negative symptoms (SANS baseline: 49.13 ± 2.30; 12-weeks follow up: 31.55 ± 2.53) compared to the TAU group (SANS baseline: 51.22 ± 2.40; 12-weeks follow up: 45.30 ± 2.93; t = 3.36; p = 0.006; Cohen's d-0.65). The current study findings suggest the efficacy of yoga as an add-on treatment for negative symptoms of schizophrenia. The effectiveness of yoga practice as a regular clinical intervention for patients needs to be explored in future studies by integrating yoga services along with other clinical services.

Impact of childhood trauma on positive and negative symptom remission in first episode psychosis

OBJECTIVE

Early life adversity is suspected to play an important role for onset and course of psychosis, but its relationship with longer-term clinical outcome is not entirely clear. In this longitudinal study, we investigated the impact of childhood trauma (CT) on positive and negative symptom remission in first episode psychosis (FEP) patients over two years.

METHODS

A total of 210 FEP patients were assessed with the Childhood Trauma Questionnaire. Patients reporting moderate to severe trauma (CT; N = 114; 54.3%) were compared to those without trauma (N-CT; N = 96; 45.7%). Positive (PSR) and negative symptom remission (NSR) were determined monthly over 24 months following established criteria using the Scale for Assessment of Positive Symptoms and the Scale for Assessment of Negative Symptoms. Global Functioning was evaluated at baseline and 24 months of follow-up.

RESULTS

Compared to N-CT patients, CT patients had achieved significantly lower rates of PSR at 12 months and significantly lower rates of NSR at 24 months. A dose-response relationship was observed between the number of trauma categories fulfilled and the number of patients not achieving PSR and NSR at these time points. Higher trauma scores were significantly associated with poor functioning and higher positive and negative symptom severity at 24 months, but not at baseline and 12 months of follow-up.

CONCLUSION

Differential effects of CT on clinical outcome may not be apparent at psychosis onset, but only become evident through poor symptomatic remission and general functioning over time. Targeted diagnostic and therapeutic efforts after illness onset might limit these detrimental consequences.

Resting-state dopaminergic cell firing in the ventral tegmental area negatively regulates affiliative social interactions in a developmental animal model of schizophrenia

Hyperdopaminergic activities are often linked to positive symptoms of schizophrenia, but their neuropathological implications on negative symptoms are rather controversial among reports. Here, we explored the regulatory role of the resting state-neural activity of dopaminergic neurons in the ventral tegmental area (VTA) on social interaction using a developmental rat model for schizophrenia. We prepared the model by administering an ammonitic cytokine, epidermal growth factor (EGF), to rat pups, which later exhibit the deficits of social interaction as monitored with same-gender affiliative sniffing. In vivo single-unit recording and microdialysis revealed that the baseline firing frequency of and dopamine release from VTA dopaminergic neurons were chronically increased in EGF model rats, and their social interaction was concomitantly reduced. Subchronic treatment with risperidone ameliorated both the social interaction deficits and higher frequency of dopaminergic cell firing in this model. Sustained suppression of hyperdopaminergic cell firing in EGF model rats by DREADD chemogenetic intervention restored the event-triggered dopamine release and their social behaviors. These observations suggest that the higher resting-state activity of VTA dopaminergic neurons is responsible for the reduced social interaction of this schizophrenia model.

Behavioral Consequences of a Combination of Gad1 Haplodeficiency and Adolescent Exposure to an NMDA Receptor Antagonist in Long-Evans Rats

Glutamate decarboxylase 67-kDa isoform (GAD67), which is encoded by the GAD1 gene, is one of the key enzymes that produce GABA. The reduced expression of GAD67 has been linked to the pathophysiology of schizophrenia. Additionally, the excitatory glutamatergic system plays an important role in the development of this disorder. Animal model studies have revealed that chronic blockade of NMDA-type glutamate receptors can cause GABAergic dysfunction and long-lasting behavioral abnormalities. Based on these findings, we speculated that Gad1 haplodeficiency combined with chronic NMDA receptor blockade would lead to larger behavioral consequences relevant to schizophrenia in a rat model. In this study, we administered an NMDAR antagonist, MK-801 (0.2 mg/kg), to CRISPR/Cas9-generated Gad1^+/− rats during adolescence to test this hypothesis. The MK-801 treated Gad1^+/− rats showed a shorter duration in each rearing episode in the open field test than the saline-treated Gad1^+/+ rats. In contrast, immobility in the forced swim test was increased and fear extinction was impaired in Gad1^+/− rats irrespective of MK-801 treatment. Interestingly, the time spent in the center region of the elevated plus-maze was significantly affected only in the saline-treated Gad1^+/− rats. Additionally, the MK-801-induced impairment of the social novelty preference was not observed in Gad1^+/− rats. These results suggest that the synergistic and additive effects of Gad1 haplodeficiency and NMDA receptor blockade during adolescence on the pathogenesis of schizophrenia may be more limited than expected. Findings from this study also imply that these two factors mainly affect negative or affective symptoms, rather than positive symptoms.