1
|
Tu Y, Fang Y, Li G, Xiong F, Gao F. Glymphatic System Dysfunction Underlying Schizophrenia Is Associated With Cognitive Impairment. Schizophr Bull 2024:sbae039. [PMID: 38581275 DOI: 10.1093/schbul/sbae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND HYPOTHESIS Despite the well-documented structural and functional brain changes in schizophrenia, the potential role of glymphatic dysfunction remains largely unexplored. This study investigates the glymphatic system's function in schizophrenia, utilizing diffusion tensor imaging (DTI) to analyze water diffusion along the perivascular space (ALPS), and examines its correlation with clinical symptoms. STUDY DESIGN A cohort consisting of 43 people with schizophrenia and 108 healthy controls was examined. We quantified water diffusion metrics along the x-, y-, and z-axis in both projection and association fibers to derive the DTI-ALPS index, a proxy for glymphatic activity. The differences in the ALPS index between groups were analyzed using a 2-way ANCOVA controlling for age and sex, while partial correlations assessed the association between the ALPS index and clinical variables. STUDY RESULTS People with schizophrenia showed a significantly reduced DTI-ALPS index across the whole brain and within both hemispheres (F = 9.001, P = .011; F = 10.024, P = .011; F = 5.927, P = .044; false discovery rate corrected), indicating potential glymphatic dysfunction in schizophrenia. The group by cognitive performance interaction effects on the ALPS index were not observed. Moreover, a lower ALPS index was associated with poorer cognitive performance on specific neuropsychological tests in people with schizophrenia. CONCLUSION Our study highlights a lower ALPS index in schizophrenia, correlated with more pronounced cognitive impairments. This suggests that glymphatic dysfunction may contribute to the pathophysiology of schizophrenia, offering new insights into its underlying mechanisms.
Collapse
Affiliation(s)
- Ye Tu
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Fang
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guohui Li
- Department of Anesthesiology and Sungical intensive CaneUnit, Xinhua Hospital A filiated to Shamghai jiaotong University school of Medicine, Shanghai, China
| | - Fei Xiong
- Department of Radiology. General Hospital of Central Theater Command, Wuhan, China
| | - Feng Gao
- Department of Anesthesiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Hubei Key Laboratory of Geriatric Anesthesia and Perioperative Brain Health, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Wuhan Clinical Research Center for Geriatric Anesthesia, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
2
|
Abplanalp SJ, Braff DL, Light GA, Joshi YB, Nuechterlein KH, Green MF. Clarifying directional dependence among measures of early auditory processing and cognition in schizophrenia: leveraging Gaussian graphical models and Bayesian networks. Psychol Med 2024:1-10. [PMID: 38287656 DOI: 10.1017/s0033291724000023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Research using latent variable models demonstrates that pre-attentive measures of early auditory processing (EAP) and cognition may initiate a cascading effect on daily functioning in schizophrenia. However, such models fail to account for relationships among individual measures of cognition and EAP, thereby limiting their utility. Hence, EAP and cognition may function as complementary and interacting measures of brain function rather than independent stages of information processing. Here, we apply a data-driven approach to identifying directional relationships among neurophysiologic and cognitive variables. METHODS Using data from the Consortium on the Genetics of Schizophrenia 2, we estimated Gaussian Graphical Models and Bayesian networks to examine undirected and directed connections between measures of EAP, including mismatch negativity and P3a, and cognition in 663 outpatients with schizophrenia and 630 control participants. RESULTS Chain structures emerged among EAP and attention/vigilance measures in schizophrenia and control groups. Concerning differences between the groups, object memory was an influential variable in schizophrenia upon which other cognitive domains depended, and working memory was an influential variable in controls. CONCLUSIONS Measures of EAP and attention/vigilance are conditionally independent of other cognitive domains that were used in this study. Findings also revealed additional causal assumptions among measures of cognition that could help guide statistical control and ultimately help identify early-stage targets or surrogate endpoints in schizophrenia.
Collapse
Affiliation(s)
- Samuel J Abplanalp
- Desert Pacific Mental Illness Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - David L Braff
- Desert Pacific Mental Illness Research Education and Clinical Center, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Gregory A Light
- Desert Pacific Mental Illness Research Education and Clinical Center, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Yash B Joshi
- Desert Pacific Mental Illness Research Education and Clinical Center, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, USA
| | - Keith H Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael F Green
- Desert Pacific Mental Illness Research, Education and Clinical Center, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
| |
Collapse
|
3
|
The effects of age and sex on cognitive impairment in schizophrenia: Findings from the Consortium on the Genetics of Schizophrenia (COGS) study. PLoS One 2020; 15:e0232855. [PMID: 32401791 PMCID: PMC7219730 DOI: 10.1371/journal.pone.0232855] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 04/22/2020] [Indexed: 01/05/2023] Open
Abstract
Recently emerging evidence indicates accelerated age-related changes in the structure and function of the brain in schizophrenia, raising a question about its potential consequences on cognitive function. Using a large sample of schizophrenia patients and controls and a battery of tasks across multiple cognitive domains, we examined whether patients show accelerated age-related decline in cognition and whether an age-related effect differ between females and males. We utilized data of 1,415 schizophrenia patients and 1,062 healthy community collected by the second phase of the Consortium on the Genetics of Schizophrenia (COGS-2). A battery of cognitive tasks included the Letter-Number Span Task, two forms of the Continuous Performance Test, the California Verbal Learning Test, Second Edition, the Penn Emotion Identification Test and the Penn Facial Memory Test. The effect of age and gender on cognitive performance was examined with a general linear model. We observed age-related changes on most cognitive measures, which was similar between males and females. Compared to controls, patients showed greater deterioration in performance on attention/vigilance and greater slowness of processing social information with increasing age. However, controls showed greater age-related changes in working memory and verbal memory compared to patients. Age-related changes (η2p of 0.001 to .008) were much smaller than between-group differences (η2p of 0.005 to .037). This study found that patients showed continued decline of cognition on some domains but stable impairment or even less decline on other domains with increasing age. These findings indicate that age-related changes in cognition in schizophrenia are subtle and not uniform across multiple cognitive domains.
Collapse
|
4
|
Greenwood TA, Lazzeroni LC, Maihofer AX, Swerdlow NR, Calkins ME, Freedman R, Green MF, Light GA, Nievergelt CM, Nuechterlein KH, Radant AD, Siever LJ, Silverman JM, Stone WS, Sugar CA, Tsuang DW, Tsuang MT, Turetsky BI, Gur RC, Gur RE, Braff DL. Genome-wide Association of Endophenotypes for Schizophrenia From the Consortium on the Genetics of Schizophrenia (COGS) Study. JAMA Psychiatry 2019; 76:1274-1284. [PMID: 31596458 PMCID: PMC6802253 DOI: 10.1001/jamapsychiatry.2019.2850] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE The Consortium on the Genetics of Schizophrenia (COGS) uses quantitative neurophysiological and neurocognitive endophenotypes with demonstrated deficits in schizophrenia as a platform from which to explore the underlying neural circuitry and genetic architecture. Many of these endophenotypes are associated with poor functional outcome in schizophrenia. Some are also endorsed as potential treatment targets by the US Food and Drug Administration. OBJECTIVE To build on prior assessments of heritability, association, and linkage in the COGS phase 1 (COGS-1) families by reporting a genome-wide association study (GWAS) of 11 schizophrenia-related endophenotypes in the independent phase 2 (COGS-2) cohort of patients with schizophrenia and healthy comparison participants (HCPs). DESIGN, SETTING, AND PARTICIPANTS A total of 1789 patients with schizophrenia and HCPs of self-reported European or Latino ancestry were recruited through a collaborative effort across the COGS sites and genotyped using the PsychChip. Standard quality control filters were applied, and more than 6.2 million variants with a genotyping call rate of greater than 0.99 were available after imputation. Association was performed for data sets stratified by diagnosis and ancestry using linear regression and adjusting for age, sex, and 5 principal components, with results combined through weighted meta-analysis. Data for COGS-1 were collected from January 6, 2003, to August 6, 2008; data for COGS-2, from June 30, 2010, to February 14, 2014. Data were analyzed from October 28, 2016, to May 4, 2018. MAIN OUTCOMES AND MEASURES A genome-wide association study was performed to evaluate association for 11 neurophysiological and neurocognitive endophenotypes targeting key domains of schizophrenia related to inhibition, attention, vigilance, learning, working memory, executive function, episodic memory, and social cognition. RESULTS The final sample of 1533 participants included 861 male participants (56.2%), and the mean (SD) age was 41.8 (13.6) years. In total, 7 genome-wide significant regions (P < 5 × 10-8) and 2 nearly significant regions (P < 9 × 10-8) containing several genes of interest, including NRG3 and HCN1, were identified for 7 endophenotypes. For each of the 11 endophenotypes, enrichment analyses performed at the level of P < 10-4 compared favorably with previous association results in the COGS-1 families and showed extensive overlap with regions identified for schizophrenia diagnosis. CONCLUSIONS AND RELEVANCE These analyses identified several genomic regions of interest that require further exploration and validation. These data seem to demonstrate the utility of endophenotypes for resolving the genetic architecture of schizophrenia and characterizing the underlying biological dysfunctions. Understanding the molecular basis of these endophenotypes may help to identify novel treatment targets and pave the way for precision-based medicine in schizophrenia and related psychotic disorders.
Collapse
Affiliation(s)
| | - Laura C. Lazzeroni
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California,Sierra Pacific Mental Illness Research Education and Clinical Center, Department of Veterans Affairs (VA) Health Care System, Palo Alto, California
| | - Adam X. Maihofer
- Department of Psychiatry, University of California, San Diego, La Jolla
| | - Neal R. Swerdlow
- Department of Psychiatry, University of California, San Diego, La Jolla
| | | | - Robert Freedman
- Department of Psychiatry, University of Colorado Health Sciences Center, Denver
| | - Michael F. Green
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, California,Desert Pacific Mental Illness Research Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Gregory A. Light
- Department of Psychiatry, University of California, San Diego, La Jolla,Desert Pacific Mental Illness Research Education and Clinical Center, VA San Diego Healthcare System, San Diego, California
| | | | | | - Allen D. Radant
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle,Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Larry J. Siever
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York,Research & Development, James J. Peters VA Medical Center, New York, New York
| | - Jeremy M. Silverman
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York,Research & Development, James J. Peters VA Medical Center, New York, New York
| | - William S. Stone
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts,Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston
| | - Catherine A. Sugar
- Department of Psychiatry and Biobehavioral Sciences, UCLA, Los Angeles, California,Department of Biostatistics, UCLA School of Public Health
| | - Debby W. Tsuang
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle,Northwest Geriatric Research Education and Clinical Center, VA Puget Sound Health Care System, Seattle, Washington
| | - Ming T. Tsuang
- Department of Psychiatry, University of California, San Diego, La Jolla
| | | | - Ruben C. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - Raquel E. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia
| | - David L. Braff
- Department of Psychiatry, University of California, San Diego, La Jolla
| |
Collapse
|
5
|
Babicz MA, Sheppard DP, Morgan EE, Paul Woods S. Where have I heard that before? A validity study of source memory indices from the California Verbal Learning Test - Second edition. Clin Neuropsychol 2019; 34:541-560. [PMID: 31084399 DOI: 10.1080/13854046.2019.1613559] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: We investigated the construct and criterion validity of the source memory (SM) indices within the California Verbal Learning Test-II (CVLT-II).Method: Participants included 77 individuals with HIV-associated neurocognitive disorders (HAND+), 287 HIV + neurocognitively normal individuals (HAND-) and 203 seronegative HIV comparisons (HIV-). CVLT-II SM impairment status (normative scores ≤1 standard deviation) was determined using Total Across-List Intrusions and Source Recognition Discriminability (d'). Participants also completed a comprehensive neuropsychological battery, assessments of everyday functioning and experimental measures of SM.Results: CVLT-II SM impairment was significantly associated with increased errors on experimental SM measures and lower scores on measures of passage recall and executive functions, but not visuospatial skills. In a logistic regression controlling for clinicodemographic factors, CVLT-II SM impairment was a significant independent predictor of HAND, with the HAND + group showing higher rates of SM impairment than both the HAND - and HIV - groups. Finally, CVLT-II SM impairment was significantly related to a composite measure of everyday functioning, but this effect disappeared after adjusting for covariates. Note that, the overall pattern of findings across this study also held when CVLT-3 normative standards were applied to the SM indices.Conclusions: Results provide initial support for the construct and criterion validity of a CVLT-II SM index in the setting of HIV disease. Future studies should examine the validity of CVLT-II SM variables in other neuropsychological populations.
Collapse
Affiliation(s)
| | - David P Sheppard
- Department of Psychology, University of Houston, Houston, TX, USA
| | - Erin E Morgan
- Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| | - Steven Paul Woods
- Department of Psychology, University of Houston, Houston, TX, USA.,Department of Psychiatry, University of California, San Diego, San Diego, CA, USA
| |
Collapse
|
6
|
Avramopoulos D. Recent Advances in the Genetics of Schizophrenia. MOLECULAR NEUROPSYCHIATRY 2018; 4:35-51. [PMID: 29998117 PMCID: PMC6032037 DOI: 10.1159/000488679] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 03/21/2018] [Indexed: 12/27/2022]
Abstract
The last decade brought tremendous progress in the field of schizophrenia genetics. As a result of extensive collaborations and multiple technological advances, we now recognize many types of genetic variants that increase the risk. These include large copy number variants, rare coding inherited and de novο variants, and over 100 loci harboring common risk variants. While the type and contribution to the risk vary among genetic variants, there is concordance in the functions of genes they implicate, such as those whose RNA binds the fragile X-related protein FMRP and members of the activity-regulated cytoskeletal complex involved in learning and memory. Gene expression studies add important information on the biology of the disease and recapitulate the same functional gene groups. Studies of alternative phenotypes help us widen our understanding of the genetic architecture of mental function and dysfunction, how diseases overlap not only with each other but also with non-disease phenotypes. The challenge is to apply this new knowledge to prevention and treatment and help patients. The data generated so far and emerging technologies, including new methods in cell engineering, offer significant promise that in the next decade we will unlock the translational potential of these significant discoveries.
Collapse
Affiliation(s)
- Dimitrios Avramopoulos
- Institute of Genetic Medicine, Johns Hopkins University, Baltimore, Maryland, USA
- Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
| |
Collapse
|
7
|
Blakey R, Ranlund S, Zartaloudi E, Cahn W, Calafato S, Colizzi M, Crespo-Facorro B, Daniel C, Díez-Revuelta Á, Di Forti M, Iyegbe C, Jablensky A, Jones R, Hall MH, Kahn R, Kalaydjieva L, Kravariti E, Lin K, McDonald C, McIntosh AM, Picchioni M, Powell J, Presman A, Rujescu D, Schulze K, Shaikh M, Thygesen JH, Toulopoulou T, Van Haren N, Van Os J, Walshe M, Murray RM, Bramon E. Associations between psychosis endophenotypes across brain functional, structural, and cognitive domains. Psychol Med 2018; 48:1325-1340. [PMID: 29094675 PMCID: PMC6516747 DOI: 10.1017/s0033291717002860] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND A range of endophenotypes characterise psychosis, however there has been limited work understanding if and how they are inter-related. METHODS This multi-centre study includes 8754 participants: 2212 people with a psychotic disorder, 1487 unaffected relatives of probands, and 5055 healthy controls. We investigated cognition [digit span (N = 3127), block design (N = 5491), and the Rey Auditory Verbal Learning Test (N = 3543)], electrophysiology [P300 amplitude and latency (N = 1102)], and neuroanatomy [lateral ventricular volume (N = 1721)]. We used linear regression to assess the interrelationships between endophenotypes. RESULTS The P300 amplitude and latency were not associated (regression coef. -0.06, 95% CI -0.12 to 0.01, p = 0.060), and P300 amplitude was positively associated with block design (coef. 0.19, 95% CI 0.10-0.28, p 0.38). All the cognitive endophenotypes were associated with each other in the expected directions (all p < 0.001). Lastly, the relationships between pairs of endophenotypes were consistent in all three participant groups, differing for some of the cognitive pairings only in the strengths of the relationships. CONCLUSIONS The P300 amplitude and latency are independent endophenotypes; the former indexing spatial visualisation and working memory, and the latter is hypothesised to index basic processing speed. Individuals with psychotic illnesses, their unaffected relatives, and healthy controls all show similar patterns of associations between endophenotypes, endorsing the theory of a continuum of psychosis liability across the population.
Collapse
Affiliation(s)
- R. Blakey
- Division of Psychiatry, University College London, London, UK
| | - S. Ranlund
- Division of Psychiatry, University College London, London, UK
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - E. Zartaloudi
- Division of Psychiatry, University College London, London, UK
| | - W. Cahn
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - S. Calafato
- Division of Psychiatry, University College London, London, UK
| | - M. Colizzi
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - B. Crespo-Facorro
- CIBERSAM, Centro Investigación Biomédica en Red Salud Mental, Madrid, Spain
- Department of Psychiatry, University Hospital Marqués de Valdecilla, School of Medicine, University of Cantabria–IDIVAL, Santander, Spain
| | - C. Daniel
- Division of Psychiatry, University College London, London, UK
| | - Á. Díez-Revuelta
- Division of Psychiatry, University College London, London, UK
- Laboratory of Cognitive and Computational Neuroscience – Centre for Biomedical Technology (CTB), Complutense University and Technical University of Madrid, Madrid, Spain
| | - M. Di Forti
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | | | - C. Iyegbe
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - A. Jablensky
- Centre for Clinical Research in Neuropsychiatry, The University of Western Australia, Perth, Western Australia, Australia
| | - R. Jones
- Division of Psychiatry, University College London, London, UK
| | - M.-H. Hall
- Psychology Research Laboratory, Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - R. Kahn
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L. Kalaydjieva
- Harry Perkins Institute of Medical Research and Centre for Medical Research, The University of Western Australia, Perth, Australia
| | - E. Kravariti
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - K. Lin
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
- Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - C. McDonald
- Department of Psychiatry, Clinical Science Institute, National University of Ireland Galway, Ireland
| | - A. M. McIntosh
- Division of Psychiatry, University of Edinburgh, Royal Edinburgh Hospital, Edinburgh, UK
- Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, UK
| | | | - M. Picchioni
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - J. Powell
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - A. Presman
- Division of Psychiatry, University College London, London, UK
| | - D. Rujescu
- Department of Psychiatry, Ludwig-Maximilians University of Munich, Munich, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatics, University of Halle Wittenberg, Halle, Germany
| | - K. Schulze
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - M. Shaikh
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
- North East London Foundation Trust, London, UK
| | - J. H. Thygesen
- Division of Psychiatry, University College London, London, UK
| | - T. Toulopoulou
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychology, Bilkent University, Main Campus, Bilkent, Ankara, Turkey
- Department of Psychology, the University of Hong Kong, Pokfulam Rd, Hong Kong SAR, China
- The State Key Laboratory of Brain and Cognitive Sciences, The University of Hong Kong, The Hong Kong Jockey Club Building for Interdisciplinary Research, Hong Kong SAR, China
| | - N. Van Haren
- Department of Psychiatry, Brain Centre Rudolf Magnus, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J. Van Os
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
- Department of Psychiatry and Psychology, Maastricht University Medical Centre, EURON, Maastricht, The Netherlands
| | - M. Walshe
- Division of Psychiatry, University College London, London, UK
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | | | - R. M. Murray
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
| | - E. Bramon
- Division of Psychiatry, University College London, London, UK
- Institute of Psychiatry Psychology and Neuroscience at King’s College London and South London and Maudsley NHS Foundation Trust, London, UK
- Institute of Cognitive Neuroscience, University College London, London, UK
| |
Collapse
|
8
|
Abstract
A recent effort has been made to better characterize the genetic architecture of schizophrenia, and apply a precision medicine model to its treatment. In pursuing this approach, it is likely that ethical concerns regarding cost-benefit uncertainties, the duty to inform and confidentiality will arise. Due to the complexity of schizophrenia's genetic profile, research efforts must be weighed against the risk to human subjects and the required consumption of valuable healthcare resources. Genetic risk profiles must be judged in conjunction with actionability and must be fully explained to patients and others potentially affected. However, confidentiality should be of paramount importance due to the presence of a risk-state phenotype, meaning the associated presence of clinically detectable neurocognitive deficiencies in those with elevated schizophrenia risk profiles.
Collapse
Affiliation(s)
- Steven Daws
- a Department of Medical Ethics & Health Policy, Perelman School of Medicine , University of Pennsylvania , Philadelphia , PA , USA
| |
Collapse
|
9
|
Blokland GAM, Mesholam-Gately RI, Toulopoulou T, del Re EC, Lam M, DeLisi LE, Donohoe G, Walters JTR, Seidman LJ, Petryshen TL. Heritability of Neuropsychological Measures in Schizophrenia and Nonpsychiatric Populations: A Systematic Review and Meta-analysis. Schizophr Bull 2017; 43:788-800. [PMID: 27872257 PMCID: PMC5472145 DOI: 10.1093/schbul/sbw146] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Schizophrenia is characterized by neuropsychological deficits across many cognitive domains. Cognitive phenotypes with high heritability and genetic overlap with schizophrenia liability can help elucidate the mechanisms leading from genes to psychopathology. We performed a meta-analysis of 170 published twin and family heritability studies of >800 000 nonpsychiatric and schizophrenia subjects to accurately estimate heritability across many neuropsychological tests and cognitive domains. The proportion of total variance of each phenotype due to additive genetic effects (A), shared environment (C), and unshared environment and error (E), was calculated by averaging A, C, and E estimates across studies and weighting by sample size. Heritability ranged across phenotypes, likely due to differences in genetic and environmental effects, with the highest heritability for General Cognitive Ability (32%-67%), Verbal Ability (43%-72%), Visuospatial Ability (20%-80%), and Attention/Processing Speed (28%-74%), while the lowest heritability was observed for Executive Function (20%-40%). These results confirm that many cognitive phenotypes are under strong genetic influences. Heritability estimates were comparable in nonpsychiatric and schizophrenia samples, suggesting that environmental factors and illness-related moderators (eg, medication) do not substantially decrease heritability in schizophrenia samples, and that genetic studies in schizophrenia samples are informative for elucidating the genetic basis of cognitive deficits. Substantial genetic overlap between cognitive phenotypes and schizophrenia liability (average rg = -.58) in twin studies supports partially shared genetic etiology. It will be important to conduct comparative studies in well-powered samples to determine whether the same or different genes and genetic variants influence cognition in schizophrenia patients and the general population.
Collapse
Affiliation(s)
- Gabriëlla A. M. Blokland
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA;,Department of Psychiatry, Harvard Medical School, Boston, MA;,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA
| | - Raquelle I. Mesholam-Gately
- Department of Psychiatry, Harvard Medical School, Boston, MA;,Commonwealth Research Center, Harvard Medical School, Boston, MA;,Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
| | - Timothea Toulopoulou
- Psychology Department, Bilkent University, Ankara, Turkey;,Department of Psychology, University of Hong Kong, Pokfulam, Hong Kong;,Department of Psychosis Studies, Institute of Psychiatry, King’s College London, London, UK
| | - Elisabetta C. del Re
- Department of Psychiatry, Harvard Medical School, Boston, MA;,Clinical Neuroscience Division, Laboratory of Neuroscience, Department of Psychiatry, Veterans Affairs Boston Healthcare System, Brockton, MA
| | - Max Lam
- Institute of Mental Health, Woodbridge Hospital, Singapore
| | - Lynn E. DeLisi
- Department of Psychiatry, Harvard Medical School, Boston, MA;,Clinical Neuroscience Division, Laboratory of Neuroscience, Department of Psychiatry, Veterans Affairs Boston Healthcare System, Brockton, MA
| | - Gary Donohoe
- School of Psychology, National University of Ireland, Galway, Ireland;,Neuropsychiatric Genetics Group, Department of Psychiatry and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland
| | - James T. R. Walters
- Institute of Psychological Medicine and Clinical Neurosciences, Cardiff University School of Medicine, Cardiff, UK
| | | | - Larry J. Seidman
- Department of Psychiatry, Harvard Medical School, Boston, MA;,Commonwealth Research Center, Harvard Medical School, Boston, MA;,Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
| | - Tracey L. Petryshen
- Psychiatric and Neurodevelopmental Genetics Unit, Department of Psychiatry and Center for Human Genetic Research, Massachusetts General Hospital, Boston, MA;,Department of Psychiatry, Harvard Medical School, Boston, MA;,Stanley Center for Psychiatric Research, Broad Institute of MIT and Harvard, Cambridge, MA
| |
Collapse
|
10
|
Abstract
First, we describe the hallmark contributions of Irv Gottesman's pioneering scholarship for schizophrenia research including concepts of polygenicity, gene × environment interactions, epigenetics and the endophenotype concept. Gottesman and colleagues' twin studies showed that genes, not social factors, mediate schizophrenia risk. He then showed that schizophrenia is highly polygenic. Next, he introduced the concept of epigenetics into schizophrenia research. Gottesman then introduced the quantitative endophenotype concept. Endophenotypes are laboratory-based measures that show deficits in schizophrenia patients and lesser deficits in their first degree "unaffected" relatives and are viewed as being more proximal to genes and having a simpler genetic architecture than are "fuzzy" qualitative diagnostic disorders. Endophenotypes offer an exciting path to gene discovery, neural circuits, genetic architecture and new treatment pathways of schizophrenia and related psychotic disorders. Second, we were asked to discuss 2 of many endophenotype Consortia and related studies, in order to illustrate the impact of Gottesman's work. We describe the Consortium on the Genetics of Schizophrenia (COGS) exploring neurocognitive and neurophysiological endophenotypes in family and case-control studies. Association, linkage, sequencing and epigenetic studies are described. The Bipolar and Schizophrenia Network for Intermediate Phenotypes (BSNIP) uses an array of endophenotypes including brain imaging in studies across the psychosis dimension, allowing for dimensional analyses. BSNIP results have led to the concept of biotypes, advancing the field. Irv Gottesman was imaginatively prescient in generating novel insights and predicting many major issues which challenge schizophrenia researchers who still use his concepts to guide current research approaches.
Collapse
Affiliation(s)
- David L Braff
- Department of Psychiatry, University of California, San Diego, La Jolla, CA;
| | - Carol A Tamminga
- Department of Psychiatry, UT Southwestern Medical School, Dallas, TX
| |
Collapse
|
11
|
Thomas ML, Green MF, Hellemann G, Sugar CA, Tarasenko M, Calkins ME, Greenwood TA, Gur RE, Gur RC, Lazzeroni LC, Nuechterlein KH, Radant AD, Seidman LJ, Shiluk AL, Siever LJ, Silverman JM, Sprock J, Stone WS, Swerdlow NR, Tsuang DW, Tsuang MT, Turetsky BI, Braff DL, Light GA. Modeling Deficits From Early Auditory Information Processing to Psychosocial Functioning in Schizophrenia. JAMA Psychiatry 2017; 74:37-46. [PMID: 27926742 PMCID: PMC5453308 DOI: 10.1001/jamapsychiatry.2016.2980] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
IMPORTANCE Neurophysiologic measures of early auditory information processing (EAP) are used as endophenotypes in genomic studies and biomarkers in clinical intervention studies. Research in schizophrenia has established correlations among measures of EAP, cognition, clinical symptoms, and functional outcome. Clarifying these associations by determining the pathways through which deficits in EAP affect functioning would suggest when and where to therapeutically intervene. OBJECTIVES To characterize the pathways from EAP to outcome and to estimate the extent to which enhancement of basic information processing might improve cognition and psychosocial functioning in schizophrenia. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional data were analyzed using structural equation modeling to examine the associations among EAP, cognition, negative symptoms, and functional outcome. Participants were recruited from the community at 5 geographically distributed laboratories as part of the Consortium on the Genetics of Schizophrenia 2 from July 1, 2010, through January 31, 2014. This well-characterized cohort of 1415 patients with schizophrenia underwent EAP, cognitive, and thorough clinical and functional assessment. MAIN OUTCOME AND MEASURES Mismatch negativity, P3a, and reorienting negativity were used to measure EAP. Cognition was measured by the Letter Number Span test and scales from the California Verbal Learning Test-Second Edition, the Wechsler Memory Scale-Third Edition, and the Penn Computerized Neurocognitive Battery. Negative symptoms were measured by the Scale for the Assessment of Negative Symptoms. Functional outcome was measured by the Role Functioning Scale. RESULTS Participants included 1415 unrelated outpatients diagnosed with schizophrenia or schizoaffective disorder (mean [SD] age, 46 [11] years; 979 males [69.2%] and 619 white [43.7%]). Early auditory information processing had a direct effect on cognition (β = 0.37, P < .001), cognition had a direct effect on negative symptoms (β = -0.16, P < .001), and both cognition (β = 0.26, P < .001) and experiential negative symptoms (β = -0.75, P < .001) had direct effects on functional outcome. The indirect effect of EAP on functional outcome was significant as well (β = 0.14, P < .001). Overall, EAP had a fully mediated effect on functional outcome, engaging general rather than modality-specific cognition, with separate pathways that involved or bypassed negative symptoms. CONCLUSIONS AND RELEVANCE The data support a model in which EAP deficits lead to poor functional outcome via impaired cognition and increased negative symptoms. Results can be used to help guide mechanistically informed, personalized treatments and support the strategy of using EAP measures as surrogate end points in early-stage procognitive intervention studies.
Collapse
Affiliation(s)
- Michael L. Thomas
- Department of Psychiatry, University of California San Diego, La Jolla, CA,VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA
| | - Michael F. Green
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA,VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gerhard Hellemann
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA,VA Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Catherine A. Sugar
- Department of Biostatistics, University of California Los Angeles School of Public Health, Los Angeles, CA
| | - Melissa Tarasenko
- Department of Psychiatry, University of California San Diego, La Jolla, CA,VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA
| | - Monica E. Calkins
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | | | - Raquel E. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Ruben C. Gur
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - Laura C. Lazzeroni
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA
| | - Keith H. Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA
| | - Allen D. Radant
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA,VA Puget Sound Health Care System, Seattle, WA
| | - Larry J. Seidman
- Department of Psychiatry, Harvard Medical School, Boston, MA,Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Larry J. Siever
- Department of Psychiatry, The Mount Sinai School of Medicine, New York, NY,James J. Peters VA Medical Center, New York, NY
| | - Jeremy M. Silverman
- Department of Psychiatry, The Mount Sinai School of Medicine, New York, NY,James J. Peters VA Medical Center, New York, NY
| | - Joyce Sprock
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - William S. Stone
- Department of Psychiatry, Harvard Medical School, Boston, MA,Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel Deaconess Medical Center, Boston, MA
| | - Neal R. Swerdlow
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - Debby W. Tsuang
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA,VA Puget Sound Health Care System, Seattle, WA
| | - Ming T. Tsuang
- Department of Psychiatry, University of California San Diego, La Jolla, CA,Center for Behavioral Genomics, and Institute for Genomic Medicine, University of California San Diego, La Jolla, CA,Harvard Institute of Psychiatric Epidemiology and Genetics, Boston, MA
| | - Bruce I. Turetsky
- Department of Psychiatry, University of Pennsylvania, Philadelphia, PA
| | - David L. Braff
- Department of Psychiatry, University of California San Diego, La Jolla, CA
| | - Gregory A. Light
- Department of Psychiatry, University of California San Diego, La Jolla, CA,VISN-22 Mental Illness, Research, Education and Clinical Center (MIRECC), VA San Diego Healthcare System, San Diego, CA
| |
Collapse
|
12
|
Zheutlin AB, Viehman RW, Fortgang R, Borg J, Smith DJ, Suvisaari J, Therman S, Hultman CM, Cannon TD. Cognitive endophenotypes inform genome-wide expression profiling in schizophrenia. Neuropsychology 2016; 30:40-52. [PMID: 26710095 DOI: 10.1037/neu0000244] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE We performed a whole-genome expression study to clarify the nature of the biological processes mediating between inherited genetic variations and cognitive dysfunction in schizophrenia. METHOD Gene expression was assayed from peripheral blood mononuclear cells using Illumina Human WG6 v3.0 chips in twins discordant for schizophrenia or bipolar disorder and control twins. After quality control, expression levels of 18,559 genes were screened for association with the California Verbal Learning Test (CVLT) performance, and any memory-related probes were then evaluated for variation by diagnostic status in the discovery sample (N = 190), and in an independent replication sample (N = 73). Heritability of gene expression using the twin design was also assessed. RESULTS After Bonferroni correction (p < 2.69 × 10-6), CVLT performance was significantly related to expression levels for 76 genes, 43 of which were differentially expressed in schizophrenia patients, with comparable effect sizes in the same direction in the replication sample. For 41 of these 43 transcripts, expression levels were heritable. Nearly all identified genes contain common or de novo mutations associated with schizophrenia in prior studies. CONCLUSION Genes increasing risk for schizophrenia appear to do so in part via effects on signaling cascades influencing memory. The genes implicated in these processes are enriched for those related to RNA processing and DNA replication and include genes influencing G-protein coupled signal transduction, cytokine signaling, and oligodendrocyte function.
Collapse
Affiliation(s)
| | - Rachael W Viehman
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles
| | | | | | - Desmond J Smith
- Department of Molecular and Medical Pharmacology, University of California Los Angeles
| | | | | | | | | |
Collapse
|
13
|
Gur RC, Braff DL, Calkins ME, Dobie DJ, Freedman R, Green MF, Greenwood TA, Lazzeroni LC, Light GA, Nuechterlein KH, Olincy A, Radant AD, Seidman LJ, Siever LJ, Silverman JM, Sprock J, Stone WS, Sugar CA, Swerdlow NR, Tsuang DW, Tsuang MT, Turetsky BI, Gur RE. Neurocognitive performance in family-based and case-control studies of schizophrenia. Schizophr Res 2015; 163:17-23. [PMID: 25432636 PMCID: PMC4441547 DOI: 10.1016/j.schres.2014.10.049] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2014] [Revised: 10/19/2014] [Accepted: 10/21/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neurocognitive deficits in schizophrenia (SZ) are established and the Consortium on the Genetics of Schizophrenia (COGS) investigated such measures as endophenotypes in family-based (COGS-1) and case-control (COGS-2) studies. By requiring family participation, family-based sampling may result in samples that vary demographically and perform better on neurocognitive measures. METHODS The Penn computerized neurocognitive battery (CNB) evaluates accuracy and speed of performance for several domains and was administered across sites in COGS-1 and COGS-2. Most tests were included in both studies. COGS-1 included 328 patients with SZ and 497 healthy comparison subjects (HCS) and COGS-2 included 1195 patients and 1009 HCS. RESULTS Demographically, COGS-1 participants were younger, more educated, with more educated parents and higher estimated IQ compared to COGS-2 participants. After controlling for demographics, the two samples produced very similar performance profiles compared to their respective controls. As expected, performance was better and with smaller effect sizes compared to controls in COGS-1 relative to COGS-2. Better performance was most pronounced for spatial processing while emotion identification had large effect sizes for both accuracy and speed in both samples. Performance was positively correlated with functioning and negatively with negative and positive symptoms in both samples, but correlations were attenuated in COGS-2, especially with positive symptoms. CONCLUSIONS Patients ascertained through family-based design have more favorable demographics and better performance on some neurocognitive domains. Thus, studies that use case-control ascertainment may tap into populations with more severe forms of illness that are exposed to less favorable factors compared to those ascertained with family-based designs.
Collapse
Affiliation(s)
- Ruben C. Gur
- Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA
| | - David L. Braff
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | - Monica E. Calkins
- Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA
| | - Dorcas J. Dobie
- Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle,
WA
| | - Robert Freedman
- Department of Psychiatry, University of Colorado Denver,
Aurora, CO
| | - Michael F. Green
- Department of Psychiatry and Biobehavioral Sciences, Geffen
School of Medicine, University of California Los Angeles, Los Angeles, CA; VA
Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Tiffany A. Greenwood
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | | | - Gregory A. Light
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | - Keith H. Nuechterlein
- Department of Psychiatry and Biobehavioral Sciences, Geffen
School of Medicine, University of California Los Angeles, Los Angeles, CA; VA
Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Ann Olincy
- Department of Psychiatry, University of Colorado Denver,
Aurora, CO
| | - Allen D. Radant
- Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle,
WA
| | - Larry J. Seidman
- Department of Psychiatry, Harvard Medical School, Boston,
MA; Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel
Deaconess Medical Center, Boston, MA
| | - Larry J. Siever
- Department of Psychiatry, The Mount Sinai School of
Medicine, New York, NY; 13James J. Peters VA Medical Center, New York, NY
| | - Jeremy M. Silverman
- Department of Psychiatry, The Mount Sinai School of
Medicine, New York, NY; 13James J. Peters VA Medical Center, New York, NY
| | - Joyce Sprock
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | - William S. Stone
- Department of Psychiatry, Harvard Medical School, Boston,
MA; Massachusetts Mental Health Center Public Psychiatry Division of the Beth Israel
Deaconess Medical Center, Boston, MA
| | - Catherine A. Sugar
- Department of Biostatistics, University of California Los
Angeles School of Public Health, Los Angeles, CA
| | - Neal R. Swerdlow
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | - Debby W. Tsuang
- Department of Psychiatry and Behavioral Sciences,
University of Washington, Seattle, WA; VA Puget Sound Health Care System, Seattle,
WA
| | - Ming T. Tsuang
- Department of Psychiatry, University of California San
Diego, La Jolla, CA; VISN-22 Mental Illness, Research, Education and Clinical Center
(MIRECC), VA San Diego Healthcare System
| | - Bruce I. Turetsky
- Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA
| | - Raquel E. Gur
- Department of Psychiatry, University of Pennsylvania,
Philadelphia, PA
| |
Collapse
|