Deconstructing Vulnerability for Psychosis: Meta-Analysis of Environmental Risk Factors for Psychosis in Subjects at Ultra High-Risk

The temporal association between social isolation, distress, and psychotic experiences in individuals at clinical high-risk for psychosis

BACKGROUND

Psychotic experiences (PEs) and social isolation (SI) seem related during early stages of psychosis, but the temporal dynamics between the two are not clear. Literature so far suggests a self-perpetuating cycle wherein momentary increases in PEs lead to social withdrawal, which, subsequently, triggers PEs at a next point in time, especially when SI is associated with increased distress. The current study investigated the daily-life temporal associations between SI and PEs, as well as the role of SI-related and general affective distress in individuals at clinical high risk (CHR) for psychosis.

METHODS

We used experience sampling methodology in a sample of 137 CHR participants. We analyzed the association between SI, PEs, and distress using time-lagged linear mixed-effects models.

RESULTS

SI did not predict next-moment fluctuations in PEs, or vice versa. Furthermore, although SI-related distress was not predictive of subsequent PEs, general affective distress during SI was a robust predictor of next-moment PEs.

CONCLUSIONS

Our results suggest that SI and PEs are not directly related on a moment-to-moment level, but a negative emotional state when alone does contribute to the risk of PEs. These findings highlight the role of affective wellbeing during early-stage psychosis development.

Exploring causal mechanisms of psychosis risk

Robust epidemiological evidence of risk and protective factors for psychosis is essential to inform preventive interventions. Previous evidence syntheses have classified these risk and protective factors according to their strength of association with psychosis. In this critical review we appraise the distinct and overlapping mechanisms of 25 key environmental risk factors for psychosis, and link these to mechanistic pathways that may contribute to neurochemical alterations hypothesised to underlie psychotic symptoms. We then discuss the implications of our findings for future research, specifically considering interactions between factors, exploring universal and subgroup-specific factors, improving understanding of temporality and risk dynamics, standardising operationalisation and measurement of risk and protective factors, and developing preventive interventions targeting risk and protective factors.

Symptomatic and Functional Outcomes Among Individuals at High Risk for Psychosis Participating in Step-Based Care

Validated, multicomponent treatments designed to address symptoms and functioning of individuals at clinical high risk for psychosis are currently lacking. The authors report findings of a study with such individuals participating in step-based care-a program designed to provide low-intensity, non-psychosis-specific interventions and advancement to higher-intensity, psychosis-specific interventions only if an individual is not meeting criteria for a clinical response. Among individuals with symptomatic or functional concerns at enrollment, 67% met criteria for a symptomatic response (median time to response=11.1 weeks), and 64% met criteria for a functional response (median time to response=8.9 weeks).

Youth Psychotic Experiences: Diagnostic Associations and Evaluation of the CAPE-16

Background

Adolescent self-reported psychotic experiences are associated with mental illness and could help guide prevention strategies. The Community Assessment of Psychic Experiences (CAPE) was developed over 20 years ago. In a rapidly changing society, where new generations of adolescents are growing up in an increasingly digital world, it is crucial to ensure high reliability and validity of the questionnaire.

Methods

In this observational validation study, we used unique transgenerational questionnaire and health registry data from the Norwegian Mother, Father, and Child Cohort, a population-based pregnancy cohort. Adolescents, aged ~14 years, responded to the CAPE-16 (n = 18,835) and fathers to the CAPE-9 questionnaire (n = 28,793). We investigated the psychometric properties of CAPE-16 through factor analyses, measurement invariance testing across biological sex, response before/ during the COVID-19 pandemic, and generations (comparison with fathers), and examined associations with later psychiatric diagnoses.

Outcomes

One third (33·4%) of adolescents reported lifetime psychotic experiences. We confirmed a three-factor structure (paranoia, bizarre thoughts, and hallucinations) of CAPE-16, and observed good scale reliability of the distress and frequency subscales (ω = ·86 and ·90). CAPE-16 measured psychotic experiences were invariant to biological sex and pandemic status. CAPE-9 was non-invariant across generations, with items related to understanding of the digital world (electrical influences) prone to bias. CAPE-16 sum scores were associated with a subsequent psychiatric diagnosis, particularly psychotic disorders (frequency: OR = 2·06; 97·5% CI = 1·70-2·46; distress: OR = 1·93; 97·5% CI = 1·63-2·26).

Interpretation

CAPE-16 showed robust psychometric properties across sex and pandemic status, and sum scores were associated with subsequent psychiatric diagnoses, particularly psychotic disorders. These findings suggest that with certain adjustments, CAPE-16 could have value as a screening tool for adolescents in the modern, digital world.

Funding

European Union's Horizon 2020 Programme, Research Council of Norway, South-Eastern Norway Regional Health Authority, NIMH, and the KG Jebsen Stiftelsen.

Polygenic risk for schizophrenia, social dispositions, and pace of epigenetic aging: Results from the Young Finns Study

Schizophrenia is often regarded as a disorder of premature aging. We investigated (a) whether polygenic risk for schizophrenia (PRSsch ) relates to pace of epigenetic aging and (b) whether personal dispositions toward active and emotionally close relationships protect against accelerated epigenetic aging in individuals with high PRSsch . The sample came from the population-based Young Finns Study (n = 1348). Epigenetic aging was measured with DNA methylation aging algorithms such as AgeAccelHannum , EEAAHannum , IEAAHannum , IEAAHorvath , AgeAccelHorvath , AgeAccelPheno , AgeAccelGrim , and DunedinPACE. A PRSsch was calculated using summary statistics from the most comprehensive genome-wide association study of schizophrenia to date. Social dispositions were assessed in terms of extraversion, sociability, reward dependence, cooperativeness, and attachment security. We found that PRSsch did not have a statistically significant effect on any studied indicator of epigenetic aging. Instead, PRSsch had a significant interaction with reward dependence (p = 0.001-0.004), cooperation (p = 0.009-0.020), extraversion (p = 0.019-0.041), sociability (p = 0.003-0.016), and attachment security (p = 0.007-0.014) in predicting AgeAccelHannum , EEAAHannum , or IEAAHannum . Specifically, participants with high PRSsch appeared to display accelerated epigenetic aging at higher (vs. lower) levels of extraversion, sociability, attachment security, reward dependence, and cooperativeness. A rather opposite pattern was evident for those with low PRSsch . No such interactions were evident when predicting the other indicators of epigenetic aging. In conclusion, against our hypothesis, frequent social interactions may relate to accelerated epigenetic aging in individuals at risk for psychosis. We speculate that this may be explained by social-cognitive impairments (perceiving social situations as overwhelming or excessively arousing) or ending up in less supportive or deviant social groups.

The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

Effectiveness of a two-stage strategy using the 16-item Prodromal Questionnaire (PQ16/fPQ16) and the Comprehensive Assessment of At Risk Mental States (CAARMS) in the early detection of Ultra High Risk (UHR) patients in Lebanon: a cross-sectional pilot study

OBJECTIVES

This study aims to identify the prevalence of Ultra High Risk (UHR) adults in a sample of patients in Lebanon and to compare screening and diagnostic tools.

METHODS

This is a cross-sectional pilot study which targeted patients aged 17-30 years willingly seeking psychiatric care in a university hospital in Beirut, Lebanon. Participants were invited to fill either the English or the French version of the Prodromal Questionnaire (respectively, PQ16 or fPQ16). The abbreviated version of the "Comprehensive Assessment of At-Risk Mental States" (CAARMS) was then administered to all participants. The latter were subsequently sorted into one of the three UHR groups - vulnerability group, attenuated psychosis (APS), intermittent psychosis (BLIPS) - or were diagnosed as suffering from a psychotic disorder.

RESULTS

Thirty-one patients participated in this study. The prevalence of positive screening on the PQ16/fPQ16 and positive diagnosis of UHR on the CAARMS were respectively of 61.29% and 45%. The APS group was the most prevalent (71.42%). A positive psychosis screening on PQ16/fPQ16 was statistically related to a UHR diagnosis on CAARMS (p-value: 0.011 on Chi2 test), OR=8.5 (95% CI: 1.4-50.9; p-value: 0.018). No relation was found between PQ16/fPQ16 results and risk stratification or between the number of "True" responses on PQ16/fPQ16 and the intensity of symptoms on CAARMS. PQ16/fPQ16 statements 5, 9, 11 and 16 predicted a UHR diagnosis on CAARMS (p-value of 0.045, 0.006, 0.045 and 0.045, respectively).

CONCLUSION

This two-stage strategy for identifying UHR patients can be adopted in a tertiary health care center.

Unhealthy behaviors associated with mental health disorders: a systematic comparative review of diet quality, sedentary behavior, and cannabis and tobacco use

Background

There are well-established literatures documenting the associations between mental disorders and unhealthy behaviors such as poor diet quality, sedentary behavior, and cannabis and tobacco use. Few studies have attempted to understand the respective findings in light of each other, however.

Objective

The purpose of this review was to assemble comparable data for each behavior-disorder association and assess the associations in terms of their overall strength. The review aimed to include a representative, but not exhaustive, range of studies that would allow for explorative comparisons.

Methods

Eligible studies were identified via Pubmed searches and citation searching, restricted to publications no older than 2015 written in English. To obtain comparable data, only studies that reported findings as odds ratios were included, and risk of bias related to study samples, behavioral measurement disparities, and control variables was assessed via sensitivity analyses. Findings for each disorder were compared on the basis of different measures of central tendency.

Results

From 3,682 records, 294 studies were included. The review found evidence of associations between each of the four unhealthy behaviors and psychosis, depression, anxiety, bipolar disorder, attention-deficit/hyperactivity disorder (ADHD), and post-traumatic stress disorder (PTSD), while personality disorder was only investigated in relation to cannabis and tobacco use. In overall comparison, the associations were generally of similar strength, and only the association between cannabis use and personality disorder was exceptional in terms of being significantly stronger than its counterparts across disorders and across behaviors. Analyses of bias risk identified some influence from behavioral measurement disparities and lack of adequate statistical control, but findings were generally robust across a range of sensitivity analyses.

Conclusion

This explorative and comparative review found that poor diet quality, sedentary behavior, and cannabis and tobacco use are about equally strongly associated with a range of different mental disorders. Given the general nature of these associations, we should probably understand them to reflect a general and shared etiology. However, the findings in this review should be regarded as tentative until confirmed by more comprehensive investigations.

Stress, Environment and Early Psychosis

Existing literature provides extended evidence of the close relationship between stress dysregulation, environmental insults, and psychosis onset. Early stress can sensitize genetically vulnerable individuals to future stress, modifying their risk for developing psychotic phenomena. Neurobiological substrate of the aberrant stress response to hypothalamic-pituitary-adrenal axis dysregulation, disrupted inflammation processes, oxidative stress increase, gut dysbiosis, and altered brain signaling, provides mechanistic links between environmental risk factors and the development of psychotic symptoms. Early-life and later-life exposures may act directly, accumulatively, and repeatedly during critical neurodevelopmental time windows. Environmental hazards, such as pre- and perinatal complications, traumatic experiences, psychosocial stressors, and cannabis use might negatively intervene with brain developmental trajectories and disturb the balance of important stress systems, which act together with recent life events to push the individual over the threshold for the manifestation of psychosis. The current review presents the dynamic and complex relationship between stress, environment, and psychosis onset, attempting to provide an insight into potentially modifiable factors, enhancing resilience and possibly influencing individual psychosis liability.

The association of social inequality with the onset, persistence, and progression of psychotic experiences along the extended psychosis phenotype: a 6-year follow-up study in a community-based sample

PURPOSE

This paper aims to investigate associations between early childhood and current indicators of socioeconomic inequality and the onset (incident), persistence and progression (increase in severity) of psychotic experiences (PEs) in a longitudinal follow-up of a community-based population.

METHODS

Households in the metropolitan area of Izmir, Turkey were contacted in a multistage clustered probability sampling frame, at baseline (T1, n = 4011) and at 6-year follow-up (T2, n = 2185). Both at baseline and follow-up, PEs were assessed using Composite International Diagnostic Interview 2.1. The associations between baseline socioeconomic features and follow-up PEs were analysed using logistic regression models. Indicators of social inequality included income, educational level, current socioeconomic status (SES), social insurance, the area resided, ethnicity, parental educational level, and SES at birth.

RESULTS

The risk of onset of PEs was significantly higher in lower education, lower SES, and slum-semi-urban areas. The persistence of PEs was significantly associated with the lowest levels of education and current SES, and rural residency. Persistent PEs were significantly and negatively associated with paternal SES at birth. Progression of PEs was significantly higher among respondents with educational achievements lower than university level and lower levels of SES, who have no social insurance and who reside in slum-semi-urban areas. Parental education and paternal SES at birth were not associated with the persistence of PEs.

CONCLUSION

Indicators of social inequality (low education, low SES, low income, and poverty in the neighbourhood) were associated with the onset and persistence of PEs and progression along the extended psychosis phenotype. The early indicators seem to have a modest life-long impact on the psychosis phenotype.

A systematic evidence map of the association between cannabis use and psychosis-related outcomes across the psychosis continuum: An umbrella review of systematic reviews and meta-analyses

While the legal status and public perception of cannabis are currently changing in many countries, one of the important considerations from a public health viewpoint is its potential association with adverse health outcomes such as the development of psychosis. We conducted an umbrella review of systematic reviews and meta-analyses using the AMSTAR-2 to assess the quality of included reviews. We further created an evidence map to visualize and facilitate the overview of the published evidence synthesis on the association between cannabis use and all psychosis-related outcomes and risk moderators in healthy, high-risk, and clinical populations. Overall, we found 32 systematic reviews and meta-analyses. Based on a synthesis of current evidence, cannabis use is associated with subclinical psychosis states (psychotic-like experiences) and traits (schizotypal personality) in the healthy population, as well as earlier onset and development of psychosis. An association with the clinical-high-risk state for psychosis, attenuated psychosis symptoms and transition to psychosis in this population could not be confirmed. An association between cannabis use and psychosis outcomes in patients with psychotic disorder could solely be confirmed regarding relapse. Whether causal effects underlie those associations has not sufficiently been addressed in the evidence synthesis to date.

The Translational Future of Stress Neurobiology and Psychosis Vulnerability: A Review of the Evidence

Psychosocial stress is a well-established risk factor for psychosis, yet the neurobiological mechanisms underlying this relationship have yet to be fully elucidated. Much of the research in this field has investigated hypothalamic-pituitary-adrenal (HPA) axis function and immuno-inflammatory processes among individuals with established psychotic disorders. However, as such studies are limited in their ability to provide knowledge that can be used to develop preventative interventions, it is important to shift the focus to individuals with increased vulnerability for psychosis (i.e., high-risk groups). In the present article, we provide an overview of the current methods for identifying individuals at high-risk for psychosis and review the psychosocial stressors that have been most consistently associated with psychosis risk. We then describe a network of interacting physiological systems that are hypothesised to mediate the relationship between psychosocial stress and the manifestation of psychotic illness and critically review evidence that abnormalities within these systems characterise highrisk populations. We found that studies of high-risk groups have yielded highly variable findings, likely due to (i) the heterogeneity both within and across high-risk samples, (ii) the diversity of psychosocial stressors implicated in psychosis, and (iii) that most studies examine single markers of isolated neurobiological systems. We propose that to move the field forward, we require well-designed, largescale translational studies that integrate multi-domain, putative stress-related biomarkers to determine their prognostic value in high-risk samples. We advocate that such investigations are highly warranted, given that psychosocial stress is undoubtedly a relevant risk factor for psychotic disorders.

Staging's determinants in early intervention youth: a retrospective study

OBJECTIVES

Since 2019 our early intervention unit has assessed help-seekers, mainly referred by psychiatric departments, and we have conducted a descriptive retrospective study. Our objective was to identify clinical determinants associated to staging at assessment for our three groups: "no psychosis", "ultra-high risk" and "first episode psychosis".

METHODS

One hundred and thirteen participants (mean age 20.05±3.28) were enrolled, mainly referred by adult psychiatry (81.4%). We tested the association of each group with the following determinants: age, gender, family history of psychosis, referral (adolescent or adult psychiatry), cognitive, depressive complaint, cannabis active consumption, and current activity (scholar or employment).

RESULTS

Multivariate analyses showed significant association with depressive symptoms (P=0.019) but an absence of family history of psychosis (P=0.002) or current activity (P=0.09) for "no psychosis" group. "Ultra-high risk" was significantly correlated with a family history of psychosis (P=0.001) and adolescent psychiatry referral (P=0.044) but an absence of depressive complaint (P=0.04). As for "first episode psychosis", we found significant cognitive complaint (P=0.026), family history (P=0.024) and current activity (0.026).

CONCLUSIONS

As all our participants were seen in tertiary care, adolescent psychiatrists were more efficient in detecting a high-risk state. "No psychosis" help-seekers presented in fact mood issues, which have been confused with attenuated psychotic symptoms by their addressers, who have probably been misled by their absence of activity integration. High-risk and characterized psychotic episodes were logically correlated with family history. Surprisingly, "first episode psychosis" youth were currently integrated in scholarly or professional life despite an active cognitive complaint. Robust studies, especially prospective cohorts, are needed to test these associations.

The effect of stressful life events on the risk for psychosis: differences between Mexican at clinical and familial high risk

Background

Stressful life events (SLEs) in the development of early psychosis have been little studied in low-income countries. This study examines differences in the prevalence of SLEs in Mexican at clinical high risk (CHR) and those with familial high risk for psychosis who do not meet CHR criteria (non-CHR FHR). We also analyze the association between SLEs and CHR.

Methods

Participants included 43 persons with CHR and 35 with non-CHR FHR. CHR criteria were assessed with the Comprehensive Assessment of At-Risk Mental State. SLEs were assessed using the Questionnaire of Stressful Life Events.

Results

Participants with CHR reported more SLEs associated with negative academic experiences than those in the non-CHR FHR group. Bullying (OR = 7.77, 95% CI [1.81, 33.32]) and low educational level (OR = 21.25, 95% CI [5.19, 46.90]) were the strongest predictors of CHR, while starting to live with a partner (OR = 0.26, 95% CI [0.10, 0.84]) was associated with a lower risk of CHR.

Conclusion

Negative school experiences increase the risk of psychosis, particularly bullying, suggesting that schools may be ideal settings for implementing individual preventive strategies to reduce risk factors and increase protective factors to improve the prognosis of those at risk of developing psychosis. In Latin America, there are multiple barriers to early intervention in psychosis. It is thus crucial to identify risk and protective factors at the onset and in the course of psychosis in order to design effective preventive interventions.

The impact of cumulative obstetric complications and childhood trauma on brain volume in young people with psychotic experiences

Psychotic experiences (PEs) occur in 5-10% of the general population and are associated with exposure to childhood trauma and obstetric complications. However, the neurobiological mechanisms underlying these associations are unclear. Using the Avon Longitudinal Study of Parents and Children (ALSPAC), we studied 138 young people aged 20 with PEs (n = 49 suspected, n = 53 definite, n = 36 psychotic disorder) and 275 controls. Voxel-based morphometry assessed whether MRI measures of grey matter volume were associated with (i) PEs, (ii) cumulative childhood psychological trauma (weighted summary score of 6 trauma types), (iii) cumulative pre/peri-natal risk factors for psychosis (weighted summary score of 16 risk factors), and (iv) the interaction between PEs and cumulative trauma or pre/peri-natal risk. PEs were associated with smaller left posterior cingulate (pFWE < 0.001, Z = 4.19) and thalamus volumes (pFWE = 0.006, Z = 3.91). Cumulative pre/perinatal risk was associated with smaller left subgenual cingulate volume (pFWE < 0.001, Z = 4.54). A significant interaction between PEs and cumulative pre/perinatal risk found larger striatum (pFWE = 0.04, Z = 3.89) and smaller right insula volume extending into the supramarginal gyrus and superior temporal gyrus (pFWE = 0.002, Z = 4.79), specifically in those with definite PEs and psychotic disorder. Cumulative childhood trauma was associated with larger left dorsal striatum (pFWE = 0.002, Z = 3.65), right prefrontal cortex (pFWE < 0.001, Z = 4.63) and smaller left insula volume in all participants (pFWE = 0.03, Z = 3.60), and there was no interaction with PEs group. In summary, pre/peri-natal risk factors and childhood psychological trauma impact similar brain pathways, namely smaller insula and larger striatum volumes. The effect of pre/perinatal risk was greatest in those with more severe PEs, whereas effects of trauma were seen in all participants. In conclusion, environmental risk factors affect brain networks implicated in schizophrenia, which may increase an individual's propensity to develop later psychotic disorders.

Plasma levels of neurotrophin 4/5, NGF and pro-BDNF influence transition to mental disorders in a sample of individuals at ultra-high risk for psychosis

BACKGROUND

Neurotrophins (NTs) and their precursors (pro-NTs) are polypeptides with important roles in neuronal development, differentiation, growth, survival and plasticity, as well as apoptosis and neuronal death. Imbalance in NT levels were observed in schizophrenia spectrum disorders, but evidence in ultra-high risk for psychosis (UHR) samples is scarce.

METHODS

A naturalistic sample of 87 non-help-seeking UHR subjects and 55 healthy controls was drawn from the general population. Blood samples were collected and NT-3, NT-4/5, BDNF, pro-BDNF, NGF, pro-NGF were analyzed through enzyme linked immunosorbent assay (ELISA). Information on cannabis and tobacco use was also collected. Logistic regression models and path analysis were used to control for confounders (tobacco, age, cannabis use).

RESULTS

NT-4/5 was significantly decreased, and pro-BDNF was significantly increased in UHR individuals compared to controls. Cannabis use and higher NGF levels were significantly related to transition to psychiatric disorders among UHR subjects. Increased pro-BDNF and decreased NT-4/5 influenced transition by the mediation of perceptual abnormalities.

CONCLUSIONS

Our study shows for the first time that NTs are altered in UHR compared to healthy control individuals, and that they can be a predictor of transition to psychiatric illnesses in this population. Future studies should employ larger naturalistic samples to confirm the findings.

Assessing the delivering of iMAgery-focused therapy for PSychosis (iMAPS) via telehealth

OBJECTIVES

To examine the feasibility and acceptability of a novel telehealth (video-conferencing software and telephone calls) imagery-based therapeutic intervention for people experiencing persecutory delusions. Utilising a multiple baseline case series design and exploring imagery-focused therapy for psychosis (iMAPS).

DESIGN

A non-concurrent A-B multiple baseline design was used.

METHODS

Participants experiencing persecutory delusions and self-reporting a psychosis or schizophrenia-spectrum diagnosis were recruited through online adverts. On completion of assessments, participants were randomly assigned to multiple baseline assessments, of between three and five sessions. Six therapy sessions followed, consisting of imagery formulation, safe-place imagery creation, compassionate imagery, imagery manipulation and rescripting. Participants completed pre- and post-measures and sessional measures via an online survey software or in semi-structured interviews. Two weeks post-intervention, a final measure was completed exploring any potential adverse effects of psychotherapy.

RESULTS

Five female participants completed all baseline and therapeutic sessions, suggesting the therapy was and mode of delivery was feasible and acceptable. Results indicate strong effect sizes across PANSS positive subscale and mood, as well as participants reporting a clinically significant change in at least one measure, for example, PSYRATS. All participants reported a reduction in the realness and compelling nature of distressing imagery.

CONCLUSIONS

Results suggest delivering a telehealth imagery-focused therapy is acceptable and feasibly delivered via telehealth. A control group and blinding of assessments would strengthen the methodological limitations present.

Predictors of transition in patients with clinical high risk for psychosis: an umbrella review

Diagnosis of a clinical high-risk (CHR) state enables timely treatment of individuals at risk for a psychotic disorder, thereby contributing to improving illness outcomes. However, only a minority of patients diagnosed with CHR will make the transition to overt psychosis. To identify patients most likely to benefit from early intervention, several studies have investigated characteristics that distinguish CHR patients who will later develop a psychotic disorder from those who will not. We aimed to summarize evidence from systematic reviews and meta-analyses on predictors of transition to psychosis in CHR patients, among characteristics and biomarkers assessed at baseline. A systematic search was conducted in Pubmed, Scopus, PsychInfo and Cochrane databases to identify reviews and meta-analyses of studies that investigated specific baseline predictors or biomarkers for transition to psychosis in CHR patients using a cross-sectional or longitudinal design. Non-peer-reviewed publications, gray literature, narrative reviews and publications not written in English were excluded from analyses. We provide a narrative synthesis of results from all included reviews and meta-analyses. For each included publication, we indicate the number of studies cited in each domain and its quality rating. A total of 40 publications (21 systematic reviews and 19 meta-analyses) that reviewed a total of 272 original studies qualified for inclusion. Baseline predictors most consistently associated with later transition included clinical characteristics such as attenuated psychotic and negative symptoms and functioning, verbal memory deficits and the electrophysiological marker of mismatch negativity. Few predictors reached a level of evidence sufficient to inform clinical practice, reflecting generalizability issues in a field characterized by studies with small, heterogeneous samples and relatively few transition events. Sample pooling and harmonization of methods across sites and projects are necessary to overcome these limitations.

Symptoms of Attenuated Psychosis Syndrome in Relatives of Clinical High-Risk Youth: Preliminary Evidence

BACKGROUND AND HYPOTHESIS

Attenuated Psychosis Syndrome (APS) impacts functioning and predicts increased risk of psychosis. Risk for developing APS itself has received minimal attention. Knowledge of familial and environmental contributions to APS symptoms would advance understanding of APS and risk for psychosis. As an initial step, this report presents the first data on APS symptoms in family members of APS patients.

STUDY DESIGN

This study utilized a discordant sibling-pair family study design. The Structured Interview for Psychosis-risk Syndromes (SIPS) was administered to 17 APS probands and 26 non-APS biological siblings. Probands and siblings were compared on positive, negative, disorganized, and general SIPS symptom scales and factors derived from those scales.

STUDY RESULTS

There was significantly greater symptom severity in probands compared to siblings on nine of 19 SIPS scales. Negative/anxiety, functioning, and positive symptom factors were identified. Probands showed significantly greater severity than siblings on the negative/anxiety and positive factors. Elevated pathology on the negative/anxiety factor best differentiated between probands and siblings, over and above the contribution of the positive factor. No difference was found for the functioning factor.

CONCLUSIONS

Results support the importance of non-familial effects on risk for APS and suggest differences in familial contribution to APS symptoms. Understanding the relative contribution of familial and environmental effects on APS symptoms may reveal important differences among APS patients, with implications for risk characterization, symptom course, and treatment selection.

Illness Phase as a Key Assessment and Intervention Window for Psychosis

The phenotype of schizophrenia, regardless of etiology, represents the most studied psychotic disorder with respect to neurobiology and distinct phases of illness. The early phase of illness represents a unique opportunity to provide effective and individualized interventions that can alter illness trajectories. Developmental age and illness stage, including temporal variation in neurobiology, can be targeted to develop phase-specific clinical assessment, biomarkers, and interventions. We review an earlier model whereby an initial glutamate signaling deficit progresses through different phases of allostatic adaptation, moving from potentially reversible functional abnormalities associated with early psychosis and working memory dysfunction, and ending with difficult-to-reverse structural changes after chronic illness. We integrate this model with evidence of dopaminergic abnormalities, including cortical D1 dysfunction, which develop during adolescence. We discuss how this model and a focus on a potential critical window of intervention in the early stages of schizophrenia impact the approach to research design and clinical care. This impact includes stage-specific considerations for symptom assessment as well as genetic, cognitive, and neurophysiological biomarkers. We examine how phase-specific biomarkers of illness phase and brain development can be incorporated into current strategies for large-scale research and clinical programs implementing coordinated specialty care. We highlight working memory and D1 dysfunction as early treatment targets that can substantially affect functional outcome.

Association between family functioning and psychotic transition in ultra-high risk adolescents and young adults

Background

Psychotic transition (PT) is a crucial stage in schizophrenia. The Comprehensive Assessment of At-Risk Mental States (CAARMS) scale can be used to identify individuals at ultra-high risk (UHR) for psychosis and to evaluate their risk of PT. Many environmental and genetic factors have been identified as contributing to the development and decompensation of schizophrenia. This study aimed to determine if the quality of family functioning is associated with PT risk in UHR individuals aged between 11 and 25 years after 1 year of follow-up.

Methods

From January to November 2017, 45 patients aged 12 to 25 consulting for psychiatric reasons were included. Twenty-six were classified as UHR of PT at the CAARMS. Family functioning was assessed by the Family Assessment Device-Global Functioning (FAD-GF). Thirty-seven of these patients (30% men, mean age 16 ± 2.5) were reassessed at 8-14 months of recruitment. Survival analysis was used to examine the impact of family functioning on PT risk.

Results

A total of 40% of UHR patients were classified as psychotic at reassessment. Survival analysis showed that better family functioning is a significant protective factor for PT in this population.

Discussion

This result suggests that the global family functioning has an impact at 1 year on the risk of PT in the population of adolescents and young adults who consult the hospital for psychiatric reasons. A family intervention may be effective in reducing PT risk in this population and should be considered as a potential therapeutic option.

Characterizing sustained social anxiety in individuals at clinical high risk for psychosis: trajectory, risk factors, and functional outcomes

BACKGROUND

While comorbidity of clinical high-risk for psychosis (CHR-P) status and social anxiety is well-established, it remains unclear how social anxiety and positive symptoms covary over time in this population. The present study aimed to determine whether there are more than one covariant trajectory of social anxiety and positive symptoms in the North American Prodrome Longitudinal Study cohort (NAPLS 2) and, if so, to test whether the different trajectory subgroups differ in terms of genetic and environmental risk factors for psychotic disorders and general functional outcome.

METHODS

In total, 764 CHR individuals were evaluated at baseline for social anxiety and psychosis risk symptom severity and followed up every 6 months for 2 years. Application of group-based multi-trajectory modeling discerned three subgroups based on the covariant trajectories of social anxiety and positive symptoms over 2 years.

RESULTS

One of the subgroups showed sustained social anxiety over time despite moderate recovery in positive symptoms, while the other two showed recovery of social anxiety below clinically significant thresholds, along with modest to moderate recovery in positive symptom severity. The trajectory group with sustained social anxiety had poorer long-term global functional outcomes than the other trajectory groups. In addition, compared with the other two trajectory groups, membership in the group with sustained social anxiety was predicted by higher levels of polygenic risk for schizophrenia and environmental stress exposures.

CONCLUSIONS

Together, these analyses indicate differential relevance of sustained v. remitting social anxiety symptoms in the CHR-P population, which in turn may carry implications for differential intervention strategies.

Perinatal maternal mental health and amygdala morphology in young adulthood

The pre- and perinatal environment is thought to play a critical role in shaping brain development. Specifically, maternal mental health and maternal care have been shown to influence offspring brain development in regions implicated in emotional regulation such as the amygdala. In this study, we used data from a neuroimaging follow-up of a prenatal birth-cohort, the European Longitudinal Study of Pregnancy and Childhood, to investigate the impact of early postnatal maternal anxiety/co-dependence, and prenatal and early-postnatal depression and dysregulated mood on amygdala volume and morphology in young adulthood (n = 103). We observed that in typically developing young adults, greater maternal anxiety/co-dependence after birth was significantly associated with lower volume (right: t = -2.913, p = 0.0045, β = -0.523; left: t = -1.471, p = 0.144, β = -0.248) and non-significantly associated with surface area (right: t = -3.502, q = 0.069, <10%FDR, β = -0.090, left: t = -3.137, q = 0.117, <10%FDR, = -0.088) of the amygdala in young adulthood. Conversely, prenatal maternal depression and mood dysregulation in the early postnatal period was not associated with any volumetric or morphological changes in the amygdala in young adulthood. Our findings provide evidence for subtle but long-lasting alterations to amygdala morphology associated with differences in maternal anxiety/co-dependence in early development.

Prevalence of tobacco smoking in people at clinical high-risk for psychosis: Systematic review and meta-analysis

Several hypotheses have been proposed to explain why individuals with psychosis consume more tobacco compared with the general population, but the reasons remain unclear. The phases predating the onset of psychosis could provide an interesting framework to clarify this association. The aim of this systematic review and meta-analysis is to provide an updated and comprehensive synthesis of the association between tobacco smoking and Clinical High Risk for Psychosis (CHRP) status. We performed a multistep systematic PRISMA/MOOSE-compliant electronic search for articles published from inception until October 1st, 2021. Web of Science was searched, complemented by a manual search of original articles reporting the outcome of tobacco consumption (defined as the number of individuals which were smoking tobacco at baseline) in a group of CHR-P patients versus healthy controls (HC). We employed quality assessment of the included studies with Newcastle Ottawa Scale (NOS). The effect size for the primary outcome was the odds ratio (OR) of smoking tobacco in CHR-P samples vs HC. We performed a random-effects model meta-analysis, assessment of heterogeneity with I² index, sensitivity analyses excluding one study at a time for primary outcome, meta-regressions with four independent moderators (mean age, female ratio, sample size, NOS) and assessment of publication bias with funnel plot and Egger's test. We included 21 independent articles, totalling 2018 CHR-P individuals (mean age of 21.35 ± 2.91 years and average female ratio of 41 ± 7 %) and 1160 HC (mean age of 22.42 ± 3.70 years and average female ratio of 45 ± 11 %). The NOS score was 6.52 ± 1.25 (range from 0 to 9). The OR of smoking status was 2.22 (95%CI 1.74-2.84, p < 0.01). Heterogeneity (I²) was 24.09 (p = 0.16). Sensitivity analyses, removing one study at a time, revealed the robustness of our main finding. Meta-regressions did not reveal any significant association between the moderators and the main outcome. Visual inspection of the funnel plot and Egger's test did not reveal evident publication bias. Our main finding of an increased OR of smokers in the CHR-P individuals compared to healthy controls corroborates the accumulation of unhealthy lifestyles in this vulnerable group. This does not demonstrate any causal association between tobacco smoking and incidence of psychosis, which should be investigated in future prospective cohorts. In conclusion, the window of opportunity represented by CHR-P status should involve more efficient physical health screening and better investigating the aetiological impact of smoking in the development of psychosis.

Reduced willingness to expend effort for rewards is associated with risk for conversion and negative symptom severity in youth at clinical high-risk for psychosis

BACKGROUND

Schizophrenia (SZ) is typically preceded by a prodromal (i.e. pre-illness) period characterized by attenuated positive symptoms and declining functional outcome. Negative symptoms are prominent among individuals at clinical high-risk (CHR) for psychosis (i.e. those with prodromal syndromes) and predictive of conversion to illness. Mechanisms underlying negative symptoms are unclear in the CHR population.

METHODS

The current study evaluated whether CHR participants demonstrated deficits in the willingness to expend effort for rewards and whether these impairments are associated with negative symptoms and greater risk for conversion. Participants included 44 CHR participants and 32 healthy controls (CN) who completed the Effort Expenditure for Reward Task (EEfRT).

RESULTS

Compared to CN, CHR participants displayed reduced likelihood of exerting high effort for high probability and magnitude rewards. Among CHR participants, reduced effort expenditure was associated with greater negative symptom severity and greater probability of conversion to a psychotic disorder on a cross-sectional risk calculator.

CONCLUSIONS

Findings suggest that effort-cost computation is a marker of illness liability and a transphasic mechanism underlying negative symptoms in the SZ spectrum.

Profile changes in admissions to a psychiatric hospitalisation unit over 15 years (2006-2021), considering the impact of the pandemic caused by SARS-CoV-2

The objective of this current work was to explore whether modification of the diagnostic criteria upon the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the impact of the COVID-19 pandemic had influenced the diagnostic and sociodemographic profiles of mental health admissions. For that purpose, we designed an observational, longitudinal, and retrospective study of the data recorded in the discharge reports of the Brief Hospitalization Unit at Castellon (Spain), between January 2006 and December 2021. The sample consisted of 7,037 participants, with a mean age of 42.1 years. The mean age of admissions, number of women, and presentation of affective disorders, addictions, and dementias all increased significantly during the DSM-5 period. Beyond diagnoses, the reduction in readmissions before the pandemic could be attributed to the use of long-acting injectable antipsychotics. In contrast, the pandemic did not change the percentage of readmissions or the volume of admissions. Also, during the pandemic period, the significant results obtained indicate that the average stay was reduced, affective disorders decreased, and addictions increased. Therefore, clinicians should consider these diagnostic and sociodemographic fluctuations when adapting clinical care, taking into account gender perspective, ageing of patients and increasing of dual and affective disorders.

Low protein-induced intrauterine growth restriction as a risk factor for schizophrenia phenotype in a rat model: assessing the role of oxidative stress and neuroinflammation interaction

A large body of evidence suggests that intrauterine growth restriction (IUGR) impedes normal neurodevelopment and predisposes the offspring to cognitive and behavioral deficits later in life. A significantly higher risk rate for schizophrenia (SZ) has been reported in individuals born after IUGR. Oxidative stress and neuroinflammation are both involved in the pathophysiology of SZ, particularly affecting the structural and functional integrity of parvalbumin interneurons (PVI) and their perineuronal nets (PNN). These anomalies have been tightly linked to impaired cognition, as observed in SZ. However, these pathways remain unexplored in models of IUGR. New research has proposed the activation of the MMP9-RAGE pathway to be a cause of persisting damage to PVIs. We hypothesize that IUGR, caused by a maternal protein deficiency during gestation, will induce oxidative stress and neuroinflammation. The activation of these pathways during neurodevelopment may affect the maturation of PVIs and PNNs, leading to long-term consequences in adolescent rats, in analogy to SZ patients. The level of oxidative stress and microglia activation were significantly increased in adolescent IUGR rats at postnatal day (P)35 as compared to control rats. PVI and PNN were decreased in P35 IUGR rats when compared to the control rats. MMP9 protein level and RAGE shedding were also increased, suggesting the involvement of this mechanism in the interaction between oxidative stress and neuroinflammation. We propose that maternal diet is an important factor for proper neurodevelopment of the inhibitory circuitry, and is likely to play a crucial role in determining normal cognition later in life, thus making it a pertinent model for SZ.

COVID-19 and New-Onset Psychosis: A Comprehensive Review

Psychosis is a multifactorial condition that typically involves delusions, hallucinations, and disorganized thought, speech or behavior. The observation of an association between infectious epidemics and acute psychosis dates back to the last century. Recently, concerns have been expressed regarding COVID-19 and the risk for the development of new-onset psychosis. This article reviewed the current evidence of a possible link between SARS-CoV-2 and risk of psychosis as an acute or post-infectious manifestation of COVID-19. We here discuss potential neurobiological and environmental factors as well as a number of challenges in ascribing a causal pathogenic relationship between SARS-CoV-2 infection and new-onset psychosis.

The 3-year progression of clinically significant psychotic-like experiences in a general adult population in Lagos, Nigeria

PURPOSE

The study assessed the 3-year progression of clinically significant psychotic-like experience (CS-PLE) symptoms in an adult general population in terms of stability or remission of symptoms and transition to psychosis.

METHODS

Participants (n = 1292) aged 18-65 years with CS-PLE were assessed at baseline for sociodemographic details, family history of mental illness, functioning status, common mental disorders, alcohol, and substance use disorders. Three years later they were reassessed for diagnosis of psychosis, presence or remission of PLE symptoms, and contact with mental health services.

RESULTS

The mean age of the participants at baseline in years was 36.56 (SD = 11.66) and there were 855 (66.2%) females. By the 3rd year follow-up, 95 (7.3%) had transited to psychosis, while 850 (65.5%) had persistent CS-PLE symptoms and the rest 347 (27.2%) were in remission. Only history of mental illness in the immediate family (HR 4.81, 95% CI 1.40-16.47, P = 0.013) and regular use of cannabis at less than 18 years of age (HR 0.65, 95% CI 0.55-0.77, P < 0.001) were the independent predictors of conversion to psychosis at 3 years.

CONCLUSION

The rate of TTP in the non-clinical population with elevated risk may be lower than that earlier reported in the western literature. Interventions aimed at preventing transition to psychosis in high risk groups must pay attention to early onset users of cannabis and those with family history of mental illness.

Higher stress response and altered quality of life in schizophrenia patients with low membrane levels of docosahexaenoic acid

Schizophrenia is a severe, chronic, and heterogeneous mental disorder that affects approximately 1% of the world population. Ongoing research aims at clustering schizophrenia heterogeneity into various "biotypes" to identify subgroups of individuals displaying homogeneous symptoms, etiopathogenesis, prognosis, and treatment response. The present study is in line with this approach and focuses on a biotype partly characterized by a specific membrane lipid composition. We have examined clinical and biological data of patients with stabilized schizophrenia, including the fatty acid content of their erythrocyte membranes, in particular the omega-3 docosahexaenoic acid (DHA). Two groups of patients of similar size were identified: the DHA- group (N = 19) with a lower proportion of membrane DHA as compared to the norm in the general population, and the DHAn group (N = 18) with a normal proportion of DHA. Compared to DHAn, DHA- patients had a higher number of hospitalizations and a lower quality of life in terms of perceived health and physical health. They also exhibited significant higher interleukin-6 and cortisol blood levels. These results emphasize the importance of measuring membrane lipid and immunoinflammatory biomarkers in stabilized patients to identify a specific subgroup and optimize non-pharmacological interventions. It could also guide future research aimed at proposing specific pharmacological treatments.

Substance use and psychotic-like experiences in young people: a systematic review and meta-analysis

This study aimed to systematically review and synthesise the available evidence on the prevalence and associations between psychotic-like experiences (PLEs) and substance use in children and adolescents aged ⩽17 years, prior to the typical age of development of prodromal symptoms of psychosis. As substance use has been associated with earlier age of psychosis onset and more severe illness, identifying risk processes in the premorbid phase of the illness may offer opportunities to prevent the development of prodromal symptoms and psychotic illness. MEDLINE, PsycINFO, and CINAHL databases were searched for chart review, case-control, cohort, twin, and cross-sectional studies. Study reporting was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist, and pooled evidence was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Searches identified 55 studies that met inclusion criteria. Around two-in-five substance users reported PLEs [rate = 0.41, 95% confidence interval (CI) 0.32-0.51; low quality evidence], and one-in-five with PLEs reported using substances (rate = 0.19, 95% CI 0.12-0.28; moderate-to-high quality evidence). Substance users were nearly twice as likely to report PLEs than non-users [odds ratio (OR) 1.77, 95% CI 1.55-2.02; moderate quality evidence], and those with PLEs were twice as likely to use substances than those not reporting PLEs (OR 1.93, 95% CI 1.55-2.41; very low quality evidence). Younger age was associated with greater odds of PLEs in substance users compared to non-users. Young substance users may represent a subclinical at-risk group for psychosis. Developing early detection and intervention for both substance use and PLEs may reduce long-term adverse outcomes.

Psychosocial factors associated with the risk of developing psychosis in a Mexican general population sample

Epidemiological evidence has linked an array of sociodemographic and psychosocial factors with an increased risk of developing psychosis. However, research in samples from low- and middle-income countries is still scarce. This study used a Mexican sample to explore (i) sociodemographic and psychosocial differences between individuals with and without a positive screen for Clinical High-Risk for psychosis (CHR), and (ii) sociodemographic and psychosocial factors associated with screening positive for CHR. The sample consisted of 822 individuals from the general population who completed an online survey. Of the participants, 17.3% (n = 142) met the CHR screening criteria. Comparisons between those who screened positive (CHR-positive group) and those who did not (Non-CHR group) showed that participants in the CHR-positive group were younger, had a lower educational level, and reported more mental health problems than the Non-CHR group. Furthermore, relative to the Non-CHR group, the CHR-positive group had a greater prevalence of medium/high risk associated with cannabis use, a higher prevalence of adverse experiences (bullying, intimate partner violence, and experiencing a violent or unexpected death of a relative or friend), as well as higher levels of childhood maltreatment, poorer family functioning, and more distress associated with the COVID-19 pandemic. Groups did not differ in sex, marital/relationship status, occupation, and socio-economic status. Finally, when examined in multivariate analyses, the variables associated with screening positive for CHR were: having an unhealthy family functioning (OR = 2.75, 95%CI 1.69-4.46), a higher risk associated with cannabis use (OR = 2.75, 95%CI 1.63-4.64), a lower level of education (OR = 1.55, 95%CI 1.003-2.54), having experienced a major natural disaster (OR = 1.94, 95%CI 1.18-3.16), having experienced a violent or unexpected death of a relative or friend (OR = 1.85, 95%CI 1.22-2.81), higher levels of childhood emotional abuse (OR = 1.88, 95%CI 1.09-3.25), physical neglect (OR = 1.68, 95%CI 1.08-2.61), and physical abuse (OR = 1.66, 95%CI 1.05-2.61), and higher COVID-related distress (OR = 1.10, 95%CI 1.01-1.20). An older age was a protective factor for screening positive for CHR (OR = 0.96, 95%CI 0.92-0.99). Overall, the findings highlight the importance of examining potential psychosocial contributors to psychosis vulnerability across different sociocultural contexts to delineate risk and protective processes relevant to specific populations and better target preventive intervention efforts.

Racial discrimination and its impact on mental health

There is evidence that racial discrimination at different levels has a major impact on mental health over the whole life span. It is related generally to poor health, with the relationship being particularly strong for mental health. All forms of structural, institutionalised, interpersonal and internalised racism as well as the cumulative impact of intersectional discrimination appear to be linked to mental health and well-being. Studies also show links between effects of racial discrimination and neurophysiology especially on the brain volume. All forms of racism need to be addressed in inter- and transdisciplinary ways in order to dismantle racial discrimination. This review provides an overview of these interconnections.

The Critical Roles of Early Development, Stress, and Environment in the Course of Psychosis

Psychotic disorders are highly debilitating with poor prognoses and courses of chronic illness. In recent decades, conceptual models have shaped understanding, informed treatment, and guided research questions. However, these models have classically focused on the adolescent and early adulthood stages immediately preceding onset while conceptualizing early infancy through all of childhood as a unitary premorbid period. In addition, models have paid limited attention to differential effects of types of stress; contextual factors such as local, regional, and country-level characteristics or sociocultural contexts; and the timing of the stressor or environmental risk. This review discusses emerging research suggesting that (a) considering effects specific to neurodevelopmental stages prior to adolescence is highly informative, (b) understanding specific stressors and levels of environmental exposures (i.e., systemic or contextual features) is necessary, and (c) exploring the dynamic interplay between development, levels and types of stressors, and environments can shed new light, informing a specified neurodevelopmental and multifaceted diathesis-stress model.

A revised and extended systematic review and meta-analysis of the relationship between childhood adversity and adult psychiatric disorder

This study aimed to systematically review the evidence for an association between adversity experienced in childhood (≤ 17 years old), and the diagnosis of psychiatric disorder in adulthood. Electronic databases (Scopus, Medline (for Ovid), EMBASE, and PsychINFO) were searched for peer-reviewed, longitudinal cohort studies examining child or adolescent exposure to adversity, and adult-diagnosed depression, anxiety, psychotic disorder, eating disorders, substance abuse disorder, illness anxiety disorder, somatoform disorder, or personality disorder. A total of 39 manuscripts were retained. Results revealed a significant association between the following childhood exposures and adult mental disorder (1.24 ≤ Odds ratios ≤ 2.09): bullying (victimhood, and frequency); emotional abuse; neglect; physical abuse; parental loss; and general maltreatment (unspecified and/or multiple adversity exposure). There were opposing results for being a victim and perpetrator of bullying, and the result for sexual abuse was not statistically significant. There was some evidence of a dose-response relationship with those exposed to multiple forms of maltreatment having more two and a half times odds of developing a mental disorder (Odds ratio = 2.59). The result for sexual abuse is likely an artefact of the prospective assessment of this adversity. In summary, there was strong evidence of an association between childhood adversity and later mental illness, and this supports previously reported meta-analyses. The evidence suggests that childhood and adolescence is an important time for risk for later mental illness, and an important period in which to focus intervention strategies for those known to have been exposed to adversity, particularly multiple adversities.

The impact of the first UK COVID-19 lockdown on presentations with psychosis to mental health services for older adults: An electronic health records study in South London

OBJECTIVES

Social distancing restrictions in the COVID-19 pandemic may have had adverse effects on older adults' mental health. Whereby the impact on mood is well-described, less is known about psychotic symptoms. The aim of this study was to compare characteristics associated with psychotic symptoms during the first UK lockdown and a pre-pandemic comparison period.

METHODS

In this retrospective observational study we analysed anonymised records from patients referred to mental health services for older adults in South London in the 16-week period of the UK lockdown starting in March 2020, and in the comparable pre-pandemic period in 2019. We used logistic regression models to compare the associations of different patient characteristics with increased odds of presenting with any psychotic symptom (defined as hallucinations and/or delusion), hallucinations, or delusions, during lockdown and the corresponding pre-pandemic period.

RESULTS

1991 referrals were identified. There were fewer referrals during lockdown but a higher proportion of presentations with any psychotic symptom (48.7% vs. 42.8%, p = 0.018), particularly hallucinations (41.0% vs. 27.8%, p < 0.001). Patients of non-White ethnicity (adjusted odds ratio (OR): 1.83; 95% confidence interval (CI): 1.13-2.99) and patients with dementia (adjusted OR: 3.09; 95% CI: 1.91-4.99) were more likely to be referred with psychotic symptoms during lockdown. While a weaker association between dementia and psychotic symptoms was found in the pre-COVID period (adjusted OR: 1.55; 95% CI: 1.19-2.03), interaction terms indicated higher odds of patients of non-White ethnicity or dementia to present with psychosis during the lockdown period.

CONCLUSIONS

During lockdown, referrals to mental health services for adults decreased, but contained a higher proportion with psychotic symptoms. The stronger association with psychotic symptoms in non-White ethnic groups and patients with dementia during lockdown suggests that barriers in accessing care might have increased during the COVID-19 pandemic.

Assessment of compliance and relapse in patients with schizophrenia before and after the onset of COVID-19 pandemic

OBJECTIVE

The aim of this study was to assess the frequency and correlates of relapse among patients with schizophrenia during the COVID-19 pandemic.

METHODS

This retrospective study included 90 adults who met DSM-IV criteria for schizophrenia. The participants were evaluated using Positive and Negative Syndrome Scale (PANSS), Compliance Rating Scale (CRS) and World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0) before and after the onset of COVID-19 pandemic.

RESULTS

The mean score of CRS was decreased after the onset of COVID-19 pandemic compared to before COVID 19 ( p < 0.001). The mean total score of PANSS scale and the mean positive subscale (P) score had increased after the onset of COVID-19 pandemic compared to before COVID 19 ( p < 0.001). Following up the news about COVID-19 regularly and decreased level of family support after the pandemic onset were associated with lower CRS scores and higher PANSS scores. In addition, the presence of infection or death with COVID-19 among family members and lower CRS scores were associated with higher scores on PANSS positive subscale.

CONCLUSIONS

The relapse rate had increased among patients with schizophrenia during COVID-19 pandemic. Non-compliance with medications and lack of family support were the main correlates of relapse in schizophrenia.Key PointsPatients with schizophrenia are at high risk for relapse during Covid-19 pandemic.Non-compliance with medications, lack of family support, COVID-19-related illness or death of family members and following the news of the pandemic are correlates of relapse in patients with schizophrenia.Psychoeducation, availability of medications and mental health services and family support may help to prevent relapse in patients with schizophrenia during pandemics.Prospective studies are needed to confirm the findings of this study.

Longstanding health risk across the life course: The influence of early-life experience on health status throughout the life span

This study tracked the longstanding effect of childhood adversities on health status over the course of a life. This study used the data from China Health and Retirement Longitudinal Study which was a nationally representative survey and documented the generation who had arrived in the middle- and old-age phase and experienced the difficult time in the early founding of PR China in their childhood. Results shown the significant associations between multiple forms of children adversities (economic distress, child neglect, child abuse, lack of friends, parental mental health problems) and health status in adolescence (from 0.068 to 0.102, p<0.01), and health status in mid and late adulthood, including self-rated general health problems (from 0.039 to 0.061, p<0.01), chronic conditions (from 0.014 to 0.120, p<0.01 except for lack of friends), body aches (from 0.016 to 0.062, p<0.01 except for child neglect), and depression (from 0.047 to 0.112, p<0.01). Meanwhile, results also shown an underlying pathway (i.e., health status in adolescence) linking childhood adversities and health status in mid and late adulthood. Results suggested that the experience of multiple forms of adversities in childhood represented a substantial source of health risk throughout life.

Heritability of Psychotic Experiences in Adolescents and Interaction With Environmental Risk

IMPORTANCE

Genetic risk factors are known to play a role in the etiology of psychotic experiences in the general population. Little is known about whether these risk factors interact with environmental risks for psychotic experiences.

OBJECTIVE

To assess etiological heterogeneity and exposure to environmental risks associated with psychotic experiences in adolescence using the twin design.

DESIGN, SETTING, AND PARTICIPANTS

This twin study, conducted from December 1, 2014, to August 31, 2020, included a UK-based sample of twin pairs aged 16 years. This investigation evaluated the extent to which the genetic variance underlying psychotic experiences and the magnitude of the heritability of psychotic experiences was moderated by exposure to 5 environmental risk factors (bullying, dependent life events, cannabis use, tobacco use, and low birth weight). Psychotic experiences were assessed by 5 self-reported measures and 1 parent-reported measure. Participants' exposure to environmental risks was assessed at birth and age 12 to 16 years. Structural equation models were used to assess differences in the variance in and heritability of psychotic experiences across these exposures, while controlling for gene-environment correlation effects. Analyses were repeated in an independent Swedish sample. Data analyses were performed from September 1, 2018, to August 31, 2020.

MAIN OUTCOMES AND MEASURES

Primary outcome measures were exposure to environmental factors, as measured by a composite score, and psychotic experiences.

RESULTS

A total of 4855 twin pairs (1926 female same-sex pairs, 1397 male same-sex pairs, and 1532 opposite-sex pairs) were included from the Twins Early Development Study (TEDS), and 6435 twin pairs (2358 female same-sex pairs, 1861 male same-sex pairs, and 2216 opposite-sex pairs) were included from the Child and Adolescent Twin Study in Sweden (CATSS). Mean age of twins from TEDS was 16.5 years. Mean age of twins from CATSS was 18.6 years. More exposure to environmental risk factors was associated with having more psychotic experiences. The relative contribution of genetic influences to psychotic experiences was lower with increasing environmental exposure for paranoia (44%; 95% CI, 33%-53% to 38%; 95% CI, 14%-58%), cognitive disorganization (47%; 95% CI, 38%-51% to 32%; 95% CI, 11%-45%), grandiosity (41%; 95% CI, 29%-52% to 32%; 95% CI, 9%-48%), and anhedonia (49%; 95% CI, 42%-53% to 37%; 95% CI, 15%-54%). This pattern was replicated for the measure of psychotic experiences in the independent Swedish replication sample. The heritability of hallucinations and parent-rated negative symptoms remained relatively constant.

CONCLUSIONS AND RELEVANCE

Findings of this twin study suggest that environmental factors play a greater role in the etiology of psychotic experiences than genetic factors. The relative importance of environmental factors is even higher among individuals exposed to environmental risks for psychotic experiences, highlighting the importance of a diathesis-stress or bioecological framework for understanding adolescent psychotic experiences.

Neuroanatomical heterogeneity and homogeneity in individuals at clinical high risk for psychosis

Individuals at Clinical High Risk for Psychosis (CHR-P) demonstrate heterogeneity in clinical profiles and outcome features. However, the extent of neuroanatomical heterogeneity in the CHR-P state is largely undetermined. We aimed to quantify the neuroanatomical heterogeneity in structural magnetic resonance imaging measures of cortical surface area (SA), cortical thickness (CT), subcortical volume (SV), and intracranial volume (ICV) in CHR-P individuals compared with healthy controls (HC), and in relation to subsequent transition to a first episode of psychosis. The ENIGMA CHR-P consortium applied a harmonised analysis to neuroimaging data across 29 international sites, including 1579 CHR-P individuals and 1243 HC, offering the largest pooled CHR-P neuroimaging dataset to date. Regional heterogeneity was indexed with the Variability Ratio (VR) and Coefficient of Variation (CV) ratio applied at the group level. Personalised estimates of heterogeneity of SA, CT and SV brain profiles were indexed with the novel Person-Based Similarity Index (PBSI), with two complementary applications. First, to assess the extent of within-diagnosis similarity or divergence of neuroanatomical profiles between individuals. Second, using a normative modelling approach, to assess the 'normativeness' of neuroanatomical profiles in individuals at CHR-P. CHR-P individuals demonstrated no greater regional heterogeneity after applying FDR corrections. However, PBSI scores indicated significantly greater neuroanatomical divergence in global SA, CT and SV profiles in CHR-P individuals compared with HC. Normative PBSI analysis identified 11 CHR-P individuals (0.70%) with marked deviation (>1.5 SD) in SA, 118 (7.47%) in CT and 161 (10.20%) in SV. Psychosis transition was not significantly associated with any measure of heterogeneity. Overall, our examination of neuroanatomical heterogeneity within the CHR-P state indicated greater divergence in neuroanatomical profiles at an individual level, irrespective of psychosis conversion. Further large-scale investigations are required of those who demonstrate marked deviation.

Effect of Cytomegalovirus on the Immune System: Implications for Aging and Mental Health

Human cytomegalovirus (HCMV) is a major modulator of the immune system leading to long-term changes in T-lymphocytes, macrophages, and natural killer (NK) cells among others. Perhaps because of this immunomodulatory capacity, HCMV infection has been linked with a host of deleterious effects including accelerated immune aging (premature mortality, increased expression of immunosenescence-linked markers, telomere shortening, speeding-up of epigenetic "clocks"), decreased vaccine immunogenicity, and greater vulnerability to infectious diseases (e.g., tuberculosis) or infectious disease-associated pathology (e.g., HIV). Perhaps not surprisingly given the long co-evolution between HCMV and humans, the virus has also been associated with beneficial effects, such as increased vaccine responsiveness, heterologous protection against infections, and protection against relapse in the context of leukemia. Here, we provide an overview of this literature. Ultimately, we focus on one other deleterious effect of HCMV, namely the emerging literature suggesting that HCMV plays a pathophysiological role in psychiatric illness, particularly depression and schizophrenia. We discuss this literature through the lens of psychological stress and inflammation, two well-established risk factors for psychiatric illness that are also known to predispose to reactivation of HCMV.

Differential effects of chronic adolescent glucocorticoid or methamphetamine on drug-induced locomotor hyperactivity and disruption of prepulse inhibition in adulthood in mice

Sensitization of dopaminergic activity has been suggested as an underlying mechanism in the psychotic symptoms of schizophrenia. Adolescent stress and chronic abuse of methamphetamine (Meth) are well-known risk factors for psychosis and schizophrenia; however it remains unknown how these factors compare in terms of dopaminergic behavioural sensitization in adulthood. In addition, while Brain-Derived Neurotrophic Factor (BDNF) has been implicated in dopaminergic activity and schizophrenia, its role in behavioural sensitization remains unclear. In this study we therefore compared the effect of chronic adolescent treatment with the stress hormone, corticosterone (Cort), or with Meth, on drug-induced locomotor hyperactivity and disruption of prepulse inhibition in adulthood in BDNF heterozygous mice and their wild-type controls, as well as on dopamine receptor gene expression. Between 6 and 9 weeks of age, the animals either received Cort in the drinking water or were treated with an escalating Meth dose protocol. In adulthood, Cort-pretreated mice showed significantly reduced Meth-induced locomotor hyperactivity compared to vehicle-pretreated mice. In contrast, Meth hyperlocomotion was significantly enhanced in animals pretreated with the drug in adolescence. There were no effects of either pretreatment on prepulse inhibition. BDNF Het mice showed greater Meth-induced hyperlocomotion and lower prepulse inhibition than WT mice. There were no effects of either pretreatment on D1 or D2 gene expression in either the dorsal or ventral striatum, while D3 mRNA was shown to be reduced in male mice only irrespective of genotype. These results suggest that in adolescence, chronically elevated glucocorticoid levels, a component of chronic stress, do not cause dopaminergic sensitization adulthood, in contrast to the effect of chronic Meth treatment in the same age period. BDNF does not appear to be involved in the effects of chronic Cort or chronic Meth.

Developmental influences on symptom expression in antipsychotic-naïve first-episode psychosis

BACKGROUND

The neurodevelopmental model of psychosis was established over 30 years ago; however, the developmental influence on psychotic symptom expression - how age affects clinical presentation in first-episode psychosis - has not been thoroughly investigated.

METHODS

Using generalized additive modeling, which allows for linear and non-linear functional forms of age-related change, we leveraged symptom data from a large sample of antipsychotic-naïve individuals with first-episode psychosis (N = 340, 12-40 years, 1-12 visits), collected at the University of Pittsburgh from 1990 to 2017. We examined relationships between age and severity of perceptual and non-perceptual positive symptoms and negative symptoms. We tested for age-associated effects on change in positive or negative symptom severity following baseline assessment and explored the time-varying relationship between perceptual and non-perceptual positive symptoms across adolescent development.

RESULTS

Perceptual positive symptom severity significantly decreased with increasing age (F = 7.0, p = 0.0007; q = 0.003) while non-perceptual positive symptom severity increased with age (F = 4.1, p = 0.01, q = 0.02). Anhedonia severity increased with increasing age (F = 6.7, p = 0.00035; q = 0.0003), while flat affect decreased in severity with increased age (F = 9.8, p = 0.002; q = 0.006). Findings remained significant when parental SES, IQ, and illness duration were included as covariates. There were no developmental effects on change in positive or negative symptom severity (all p > 0.25). Beginning at age 18, there was a statistically significant association between severity of non-perceptual and perceptual symptoms. This relationship increased in strength throughout adulthood.

CONCLUSIONS

These findings suggest that as maturation proceeds, perceptual symptoms attenuate while non-perceptual symptoms are enhanced. Findings underscore how pathological brain-behavior relationships vary as a function of development.

The mediating effect of brain-derived neurotrophic factor levels on childhood trauma and psychiatric symptoms in patients with first-episode schizophrenia

BACKGROUND

Previous studies have implicated childhood trauma and abnormal brain-derived neurotrophic factor in the pathogenesis of schizophrenia. Here, we explored whether brain-derived neurotrophic factor levels mediated the relationship between childhood trauma and psychopathological symptoms in patients with first-episode schizophrenia.

METHODS

Patients with first-episode schizophrenia (n = 192) and healthy controls (n = 136) were enrolled. Childhood traumatic experiences and psychopathology were assessed by Childhood Trauma Questionnaire and Positive and Negative Syndrome Scale, respectively. Enzyme-linked immunosorbent assay was used to quantify brain-derived neurotrophic factor levels.

RESULTS

The patients with first-episode schizophrenia experienced more severe childhood trauma and had lower serum brain-derived neurotrophic factor levels than healthy controls. Emotional abuse and Childhood Trauma Questionnaire total score showed positive correlation with Positive and Negative Syndrome Scale positive, general psychopathological subscore and total score. Emotional neglect showed positive correlation with Positive and Negative Syndrome Scale positive subscore. Physical neglect was positively associated with Positive and Negative Syndrome Scale negative subscore. Emotional neglect and Childhood Trauma Questionnaire total score were negatively correlated with serum brain-derived neurotrophic factor levels. The serum brain-derived neurotrophic factor levels mediated the relationship between both Childhood Trauma Questionnaire total score and Positive and Negative Syndrome Scale total score and negative symptoms in the patients. The brain-derived neurotrophic factor levels also mediated the relationship between emotional neglect and Positive and Negative Syndrome Scale total score in the patients.

CONCLUSION

Childhood trauma might contribute to the clinical symptoms of schizophrenia by affecting brain-derived neurotrophic factor levels. Perhaps we can prevent schizophrenia by reducing childhood traumatic experiences.

Neural Correlates of Facial Emotion Recognition in Non-help-seeking University Students With Ultra-High Risk for Psychosis

Background

Since the introduction of the neurodevelopmental perspective of schizophrenia research on individuals at ultra-high risk for psychosis (UHR) has gained increasing interest, aiming at early detection and intervention. Results from fMRI studies investigating behavioral and brain functional changes in UHR during facial emotion recognition, an essential component of social cognition, showed heterogenous results, probably due clinical diversity across these investigations. This fMRI study investigated emotion recognition in a sub-group of the UHR spectrum, namely non-help-seeking, drug-naïve UHR with high cognitive functioning to reveal the neurofunctional underpinnings of their social functioning in comparison to healthy controls.

Methods

Two large cohorts of students from an elite University (n 1 = 4,040, n 2 = 4,364) were screened firstly with the Prodromal Questionnaires and by surpassing predefined cut-offs then interviewed with the semi-structured Interview for Psychosis-Risk Syndromes to verify their UHR status. Twenty-one identified non-help-seeking UHR and 23 non-UHR control subjects were scanned with functional magnetic resonance imaging while classifying emotions (i.e., neutral, happy, disgust and fear) in a facial emotion recognition task.

Results

Behaviorally, no group differences were found concerning accuracy, reaction times, sensitivity or specificity, except that non-help-seeking UHR showed higher specificity when recognizing neutral facial expressions. In comparison to healthy non-UHR controls, non-help-seeking UHR showed generally higher activation in the superior temporal and left Heschl's gyrus as well as in the somatosensory, insular and midcingulate cortex than the control subjects during the entire recognition task regardless of the emotion categories. In an exploratory analysis, in the non-help-seeking UHR group, functional activity in the left superior temporal gyrus was significantly correlated with deficits in the ability to experience emotions at uncorrected statistical thresholds.

Conclusions

Compared to healthy controls, non-help-seeking UHR show no behavioral deficits during facial emotion recognition, but functional hyperactivities in brain regions associated with this cognitive process. Our study may inspire future early intervention and provide loci for treatment using neural stimulation.

A cycloid psychosis relapse and SARS-CoV-2 concomitant infection

N/A.

Examining the variability of neurocognitive functioning in individuals at clinical high risk for psychosis: a meta-analysis

This study aims to meta-analytically characterize the presence and magnitude of within-group variability across neurocognitive functioning in young people at Clinical High-Risk for psychosis (CHR-P) and comparison groups. Multistep, PRISMA/MOOSE-compliant systematic review (PROSPERO-CRD42020192826) of the Web of Science database, Cochrane Central Register of Reviews and Ovid/PsycINFO and trial registries up to July 1, 2020. The risk of bias was assessed using a modified version of the NOS for cohort and cross-sectional studies. Original studies reporting neurocognitive functioning in individuals at CHR-P compared to healthy controls (HC) or first-episode psychosis (FEP) patients were included. The primary outcome was the random-effect meta-analytic variability ratios (VR). Secondary outcomes included the coefficient of variation ratios (CVR). Seventy-eight studies were included, relating to 5162 CHR-P individuals, 2865 HC and 486 FEP. The CHR-P group demonstrated higher variability compared to HC (in descending order of magnitude) in visual memory (VR: 1.41, 95% CI 1.02-1.94), executive functioning (VR: 1.31, 95% CI 1.18-1.45), verbal learning (VR: 1.29, 95% CI 1.15-1.45), premorbid IQ (VR: 1.27, 95% CI 1.09-1.49), processing speed (VR: 1.26, 95% CI 1.07-1.48), visual learning (VR: 1.20, 95% CI 1.07-1.34), and reasoning and problem solving (VR: 1.17, 95% CI 1.03-1.34). In the CVR analyses the variability in CHR-P population remains in the previous neurocognitive domains and emerged in attention/vigilance, working memory, social cognition, and visuospatial ability. The CHR-P group transitioning to psychosis showed greater VR in executive functioning compared to those not developing psychosis and compared to FEP groups. Clinical high risk for psychosis subjects shows increased variability in neurocognitive performance compared to HC. The main limitation of this study is the validity of the VR and CVR as an index of variability which has received debate. This finding should be explored by further individual-participant data research and support precision medicine approaches.

Initial Presentation of OCD and Psychosis in an Adolescent during the COVID-19 Pandemic

The COVID-19 pandemic is unparalleled in recent history when accounting for the true disease burden and dramatic impact on physical and mental health. Due to its infectious pathology, COVID-19 presents with a variety of symptoms including neuropsychiatric complications. Moreover, factors such as quarantine, social isolation, and fear of illness have negatively impacted the health of non-COVID-19 patients. There has been significant literature reporting new-onset psychiatric illness in all global populations including those without history of psychiatric illness. This report discusses an adolescent male without prior psychiatric history presenting with new onset symptoms of obsessive-compulsive disorder and psychosis in the context of COVID-19. There are considerable reports describing new-onset obsessive-compulsive disorder, albeit conflicting in terms of prevalence and exacerbations in the setting of COVID-19 in both adult and adolescent populations but limited reports of new-onset psychosis in those same populations and setting.