Multivantaged assessment of depression in schizophrenia

The Association of the Oral Microbiota with the Effects of Acid Stress Induced by an Increase of Brain Lactate in Schizophrenia Patients

The altered cerebral energy metabolism central to schizophrenia can be linked to lactate accumulation. Lactic acid is produced by gastrointestinal bacteria, among others, and readily crosses the blood-brain barrier, leading to the brain acidity. This study aimed to examine the association of the oral microbiota with the effects of acid stress induced by an increase of brain lactate in schizophrenia patients. The study included patients with a diagnosis of acute polyphasic psychotic disorder meeting criteria for schizophrenia at 3-month follow-up. Results: Individuals with a significantly higher total score on the Positive and Negative Syndrome Scale had statistically significantly lower lactate concentrations compared to those with a lower total score and higher brain lactate. We observed a positive correlation between Actinomyces and lactate levels in the anterior cingulate cap and a negative correlation between bacteria associated with lactate metabolism and some clinical assessment scales. Conclusions: Shifts in the oral microbiota in favour of lactate-utilising bacterial genera may represent a compensatory mechanism in response to increased lactate production in the brain. Assessment of neuronal function mediated by ALA-LAC-dependent NMDA regulatory mechanisms may, thus, support new therapies for schizophrenia, for which acidosis has become a differentiating feature of individuals with schizophrenia endophenotypes.

[Clinical-psychopathological aspects of therapeutic effects of agomelatine (valdoxan) and its place in perfection of methods of therapy of postschizophrenic depressive disorders]

AIM

To determine a therapeutic effect of agomelatine (valdoxan) on post-schizophrenic depression (PSD), taking into account its psychopathological structure.

MATERIAL AND METHODS

A total of 33 patients of both sexes (average age was 32.1 yrs) with symptoms of post-schizophrenic depression (F20.4 according to ICD-10) were examined by using clinical and psychometric methods in the dynamics of shift-like schizophrenia. HAMD-17, PANSS and CGI-S scales were applied. All the patients were subdivided into groups: mild, moderate and severe depressions. Valdoxan was used at a dose of 25-50 mg/day for 28 days along with preceding antipsychotic therapy at maintenance doses. Evaluation of the efficacy of treatment was carried out according to percentage reduction of average total score (ATS) in dynamics.

RESULTS

A significant effect of valdoxan, with 73.5% of PANSS score reduction and quicker response to treatment, was identified. Therapeutic effect of valdoxan on separate components of PSD was uneven. The decrease of depressive disorders per se assessed by HAМD-17 and PANSS G-subscale was equally high (78.4 and 78.2%, respectively). Therapeutic reduction of negative disorders according to PANSS N-subscale was the lowest, at the level of 'good' effect (53.6%). In 27.3%, negative disorders were irreversible and were assessed as schizophrenic defect; in 72.7% of patients they were diagnosed as 'secondary' negative symptoms in atypical depression. In the subgroups of mild, moderate, and severe depression, the reduction of negative disorders was 62.4; 44.2 and 60.8%, respectively, and that of total PANSS score were 81.5; 66.1, and 78.6%, i.e. there was no correlation between these variables.

CONCLUSION

Agomelatin (valdoxan) is an effective medication for optimization of methods of PSD treatment, providing the therapeutic effect at the level of significant or complete reduction of symptoms. The quality (depth) and rate of formation of response in the dynamics of course treatment are determined not by the severity of depressive disorders in PSD structure, but by the ratio between negative (deficit) symptoms and 'secondary' symptoms, reflecting the degree of progression of the main disease.

The psychometric validity of the Center for Epidemiological Studies - Depression Scale (CES-D) in first episode schizophrenia spectrum

Depressive pathology is common in first-episode schizophrenia spectrum disorders (FES), and is frequently assessed using the Center for Epidemiological Studies - Depression Scale (CES-D), an instrument designed for use in community samples. Despite its widespread use, no prior study has examined the psychometric validity of the CES-D in assessing depressive pathology in FES. The aim of this study was to examine the psychometric validity of the CES-D in FES. This study involved secondary analysis of baseline data from a single blind, randomized controlled trial of vocational intervention for individuals with FES (N=91; age range: 15-25 years). Measures used were: CES-D, Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Negative Symptoms (SANS), and Structured Clinical Interview for DSM-IV-TR (SCID-I/P). The CES-D strongly correlated with the depression subscale of the BPRS, and with the presence of full-threshold depressive disorder on the SCID-I/P. There was minimal overlap between the CES-D and SANS, with weak correlations emerging for avolition and anhedonia, and not for affective flattening, alogia, and attention. The CES-D cut-off of ≥23 produced high sensitivity and specificity values for determining full-threshold comorbid depressive disorder. Such findings indicate that the CES-D is effective for assessing and measuring depressive pathology in FES.

Altered emotional experiences attributed to antipsychotic medications - A potential link with estimated dopamine D2 receptor occupancy

Altered emotional experiences in response to antipsychotics may increase the burden of disease in patients with schizophrenia. In a large cross-sectional study, patients with schizophrenia completed the Subjects Reaction to Antipsychotics questionnaire (SRA) to assess whether they attributed altered emotional experiences (flattened affect or depressive symptoms) to their antipsychotics. Association with antipsychotic D2 receptor affinity and occupancy was examined using logistic regression. We compared antipsychotic-attributed emotional experiences between patients using antipsychotic monotherapy and combination therapy. Of the 1298 included patients, 23% attributed flattened affect to their antipsychotics and 16% attributed depressive symptoms to their antipsychotics, based on the SRA. No differences were observed between antipsychotics in patients on monotherapy. We discuss that within these patients' relatively low dose range, altered emotional experiences did not appear to relate to the level of D2 receptor affinity of antipsychotic monotherapy. Patients using antipsychotic combination therapy (22%) were more likely to attribute depressive symptoms to their antipsychotics than patients using antipsychotic monotherapy (OR [95%CI]=1.443 [1.033-2.015]); possibly due to higher D2 receptor occupancies as estimated by dose equivalents.

Psychometric properties of the self-report version of the Quick Inventory of Depressive Symptoms (QIDS-SR₁₆) questionnaire in patients with schizophrenia

BACKGROUND

Self-report instruments for the assessment of depressive symptoms in patients with psychotic disorders are scarce. The Quick Inventory of Depressive Symptoms (QIDS-SR16) may be a useful self-report instrument, but has received little attention in this field. This paper aimed to test the psychometric properties of the QIDS-SR16 questionnaire in patients with a psychotic disorder.

METHODS

Patients diagnosed with a psychotic disorder from health care institutions in The Netherlands were included in the study. Depressive symptoms were assessed with the QIDS-SR16 and the Calgary Depression Scale for Schizophrenia (CDSS). Psychotic symptoms were assessed with the Positive and Negative Syndrome Scale (PANSS) and extrapyramidal symptoms (EPS) with three EPS rating scales. Spearman's correlation coefficients were used to compare the total score of the QIDS-SR16 with the total scores of the CDSS, PANSS-subscales and EPS rating scales.

RESULTS

In a sample of 621 patients with psychotic disorders, the QIDS-SR16 showed good internal consistency (α = 0.87). The QIDS-SR16 correlated moderately with the CDSS (r = 0.44) and the PANSS subscale for emotional distress (r = 0.47). The QIDS-SR16 showed weak correlation with the PANSS subscale for negative symptoms (r = 0.28) and minimal correlation with EPS rating scales (r = 0.09-0.16).

CONCLUSIONS

The QIDS-SR16 may reliably assess depressive symptoms in patients with psychotic disorders, but its concurrent validity with the CDSS was rather poor in this population. We would recommend developing a new self-report questionnaire for the assessment of depressive symptoms in patients with psychotic disorders.

A Longitudinal Examination of the Moderating Effects of Symptoms on the Relationship between Functional Competence and Real World Functional Performance in Schizophrenia

BACKGROUND

Many individuals with schizophrenia experience remission of prominent positive symptoms but continue to experience impairments in real world functioning. Residual negative and depressive symptoms may have a direct impact on functioning and impair patients' ability to use the cognitive and functional skills that they possess (competence) in the real world (functional performance).

METHODS

136 individuals (100 men, 36 women) with schizophrenia were classified as having primarily positive symptoms, primarily negative symptoms, primarily depressive symptoms, or undifferentiated symptom profiles. Performance based measures of cognition and adaptive and interpersonal functional competence were used, along with ratings of real world behavior by high contact clinicians. Assessments were performed at baseline and at an 18-month follow-up.

RESULTS

The relationships between neurocognition and capacity / performance were not moderated by symptom group ps > .091; neurocognition predicted capacity and performance for all groups ps < .001. The relationship between adaptive competence and adaptive performance was moderated by symptom group, ps < .01, such that baseline competence only predicted future performance ratings for participants with primarily positive or undifferentiated symptoms, and not for individuals with primarily negative or depressive symptoms. This same moderation effect was found on the relationship between interpersonal competence and interpersonal performance, ps < .002.

CONCLUSIONS

Residual negative and depressive symptoms are distinct constructs that impede the use of functional skills in the real world. Depressive symptoms are often overlooked in schizophrenia but appear to be an important factor that limits the use of functional ability in real world environments.

A systematic review of instruments to measure depressive symptoms in patients with schizophrenia

BACKGROUND

Depressive symptoms require accurate recognition and monitoring in clinical practice of patients with schizophrenia. Depression instruments developed for use in depressed patients may not discriminate depressive symptoms from negative psychotic symptoms.

OBJECTIVE

We reviewed depression instruments on their reliability and validity in patients with schizophrenia.

METHODOLOGY

A systematic literature search was carried out in three electronic databases. Psychometric properties were extracted for those instruments of which reliability, divergent, concurrent and predictive validity were reported in one or more publications.

RESULTS

Forty-eight publications described the reliability and validity of six depression instruments in patients with schizophrenia. The only self-report was the Beck Depression Inventory (BDI). The Brief Psychiatric Rating Scale-Depression subscale (BPRS-D), Positive and Negative Syndrome Scale-Depression subscale (PANSS-D), Hamilton Rating Scale for Depression (HAMD), Montgomery Asberg Depression Rating Scale (MADRS) and Calgary Depression Scale for Schizophrenia (CDSS) were clinician rated. All instruments were reliable for the measurement of depressive symptoms in patients with schizophrenia. The CDSS most accurately differentiated depressive symptoms from other symptoms of schizophrenia (divergent validity), correlated well with other depression instruments (concurrent validity), and was least likely to miss cases of depression or misdiagnose depression (predictive validity).

CONCLUSIONS

We would recommend to use the CDSS for the measurement of depressive symptoms in research and in daily clinical practice of patients with schizophrenia. A valid self-report instrument is to be developed for the use in clinical practice.

Depressed mood and its functional correlates in institutionalized schizophrenia patients

OBJECTIVE

To determine the frequency of depressed mood in institutionalized schizophrenia patients and its association with illness-related and functional variables.

METHODS

Out of 657 institutionalized schizophrenia patients, patients with depressed mood were identified and compared to non-depressed patients, matching for potential confounders.

RESULTS

Forty-eight (7.3%) patients had moderate to severe depressed mood. They were younger, more educated and had fewer years since their first hospitalization than non-depressed patients. After matching for these variables, depressed patients showed more positive symptoms and exhibited better social and cognitive functioning. When controlling for negative symptoms, the differences in social and cognitive functioning between the depressed and non-depressed patients disappeared, and depressed patients showed more positive symptoms and more impaired impulse control.

CONCLUSIONS

Unlike the negative impact of depressed mood in other populations, this study shows that symptoms of depressed mood may identify a subgroup of institutionalized schizophrenia patients who show better functioning across a variety of indicators. Future studies should determine differential treatment responses and long-term outcomes of these patients.

Possible Relationship Between Testosterone and Comorbid Major Depressive Episode in Male Patients With Schizophrenia Treated With Typical Antipsychotic Medications

In this cross-sectional study, the author tested the hypothesis that serum testosterone levels were associated with depressive illness in chronic male schizophrenia patients. The subjects were 49 male inpatients meeting DSM-IV criteria for schizophrenia treated with typical antipsychotic medications. The author found that the schizophrenia patients with major depressive episodes (MDE) had been taking significantly higher dosages of antipsychotic medications than those without an MDE. Also, there was a trend for the serum testosterone concentration to be lower in schizophrenia patients with an MDE. It is suggested that we should be aware of testosterone levels when we find depression in chronic male schizophrenia patients, especially those treated with high-dose typical antipsychotic medications.

Depressive symptoms in chronic schizophrenia patients: any differences between patients with and without a major depressive episode?

The author investigated the differences between schizophrenia patients with and without a major depressive episode (MDE) using the Japanese Calgary Depression Scale for Schizophrenics. The total depression score was correlated with the dosage of antipsychotics in patients without an MDE, but such a correlation was not found in patients with an MDE.

Double-blind antiglucocorticoid treatment in schizophrenia and schizoaffective disorder: a pilot study

BACKGROUND

Antiglucocorticoids, such as ketoconazole, have been investigated as antidepressant agents in major depression and other conditions. Despite evidence that a significant number of patients with schizophrenia and schizoaffective disorder are both hypercortisolemic and depressed, the antidepressant effects of antiglucocorticoids have never been assessed in these populations.

METHODS

Fifteen symptomatic patients with diagnoses of schizophrenia or schizoaffective disorder, who were at least partially treatment-resistant, were treated with ketoconazole, up to 800 mg/day, (n = 8) or placebo (n = 7) for four weeks in a double-blind manner. The study medication was added to a pre-stabilized antipsychotic and/or antidepressant medication regimen.

RESULTS

Ketoconazole treatment, compared to placebo, was associated with significant improvements in observer-rated depression, but not in subjectively rated depression, positive or negative psychotic symptom ratings, or cognitive performance scores.

CONCLUSIONS

These pilot data partially support the hypothesis that antiglucocorticoids reduce depressive symptoms in patients with schizophrenia and schizoaffective disorder, although objective and subjective ratings may not be similarly affected during a four-week course of treatment. Further studies with larger sample sizes, more extensive endocrine assessments and longer duration of drug administration seem warranted.

The relationship of patient-administered outcome assessments to quality of life and physician ratings: validity of the BASIS-32

The reliability and validity of a patient-administered version of the Behavior and Symptom Identification Scale (BASIS-32) was compared to the original interviewer-administered version. The construct validity of BASIS-32 subscales was assessed by examining their relationship with functional and satisfaction quality of life and physician ratings of functional and clinical status. A total of 361 acute psychiatric inpatients were given a self-administered BASIS-32, nurse-administered Lehman's Quality of Life Interview (QOLI), and Psychiatrist Assessment Form at admission and discharge. The original factor structure, internal consistency reliability, discriminant validity, and sensitivity to change were replicated. The patient-administered BASIS-32 is equally as reliable and valid as the interview. Construct validity analyses revealed that functional and satisfaction QOLI indices were moderately related to the BASIS-32 in the hypothesized directions. All satisfaction scales were associated with significantly less severity. Physician ratings were only mildly related to the subscales. The BASIS-32 used in outcome assessments with inpatients provides important and unique perspectives on functional and clinical status that are not tapped by clinician-rated assessments.

Depression in schizophrenia: a descriptive study

OBJECTIVE

To assess the level of depressive symptomatology among a group of patients with schizophrenia, both inpatients and outpatients, and speculate as to the reasons why differences among the groups may be occurring.

METHOD

Fifty inpatients of Baillie Henderson Hospital, a chronic stay psychiatric hospital in Queensland, and 44 outpatients of this hospital were assessed on a number of measures including the Positive and Negative Syndrome Scale for Schizophrenia, Abnormal Involuntary Movements Scale, Hamilton Rating Scale for Depression and Beck Depression Inventory. All patients were assessed in a structured interview for 35-40 minutes by the same clinician. A chart review also occurred. The chief outcome variable was a Hamilton Depression Rating Scale of 17 or greater.

RESULTS

Clinically significant depression, as defined by a Hamilton Depression score of 17 or greater, was found in 10% (n = 5) of the inpatient sample. Of the outpatient sample, 4.5% (n = 2) showed a clinically significant depression, which was not significantly different to the inpatient group. The prevalence of mild to moderate depression, as defined by a Hamilton Depression score of between 10 and 17, was 42% in the inpatient group and 47.7% in the outpatient group. There was no significant difference between the two groups on the mean Hamilton Depression scores.

CONCLUSIONS

The results suggest a high level of depressive symptomatology in patients with schizophrenia. As suicide is common in this group, this finding is important. Self-reporting of this problem by patients with schizophrenia, by means of questionnaire, is feasible and provides comparable results to objective clinician ratings.