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Bai Y, Liang X, Xia L, Yu S, Wu F, Li M. Association between air pollutants and four major mental disorders: Evidence from a Mendelian randomization study. ECOTOXICOLOGY AND ENVIRONMENTAL SAFETY 2024; 283:116887. [PMID: 39208533 DOI: 10.1016/j.ecoenv.2024.116887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 07/10/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Existing epidemiological studies have indicated a correlation between air pollutants and the occurrence of mental disorders. However, it is difficult to estimate the causal relationship between the two because of the limitations of traditional epidemiological research. In our study, we aimed to extensively explore the causal relationship between five types of air pollutants and four types of mental disorders. METHODS Based on the IEU OPEN GWAS database, we performed a two-sample MR analysis. The primary analysis method utilized was the inverse variance weighted (IVW) method, supplemented by the MR-Egger method and the weighted median method. Additionally, we conducted sensitivity analyses with the Cochran's Q statistic method, the leave-one-out method, and the MR-Egger intercept. We chose at least 4 GWAS datasets for each of the four psychiatric diseases and conducted a meta-analysis of our results of the MR analysis. RESULTS The meta-analysis's findings demonstrated a causal link between depression and PM2.5 (OR=1.020, 95 %CI: (1.010,1.030), P=0.001). PM10 and schizophrenia are also causally related (OR=1.136, 95 %CI: (1.034,1.248), P=0.008). Nitrogen oxides and bipolar disorder have a causal relationship (OR=1.002, 95 %CI: (1.000,1.003), P=0.022). Nitrogen oxides and schizophrenia have a high causal association (OR=1.439, 95 %CI: (1.183,1.752), P<0.001). CONCLUSION This study observed a causal association between increased concentrations of PM2.5, PM10, and nitrogen oxides and the occurrence of depression, schizophrenia, and bipolar disorder. Our research findings have certain guiding implications for treating and preventing mental disorders.
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Affiliation(s)
- Yushuai Bai
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China
| | - Xiao Liang
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China
| | - Lin Xia
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China
| | - Shuaixin Yu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China
| | - Fugui Wu
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China
| | - Man Li
- Department of Epidemiology and Statistics, School of Public Health, Hebei Medical University, Hebei Key Laboratory of Environment and Human Health, Shijiazhuang, Hebei 050000, China.
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Liu R, Li D, Ma Y, Tang L, Chen R, Tian Y. Air pollutants, genetic susceptibility and the risk of schizophrenia: large prospective study. Br J Psychiatry 2024:1-9. [PMID: 39117363 DOI: 10.1192/bjp.2024.118] [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: 08/10/2024]
Abstract
BACKGROUND Evidence linking air pollutants and the risk of schizophrenia remains limited and inconsistent, and no studies have investigated the joint effect of air pollutant exposure and genetic factors on schizophrenia risk. AIMS To investigate how exposure to air pollution affects schizophrenia risk and the potential effect modification of genetic susceptibility. METHOD Our study was conducted using data on 485 288 participants from the UK Biobank. Cox proportional hazards models were used to estimate the schizophrenia risk as a function of long-term air pollution exposure presented as a time-varying variable. We also derived the schizophrenia polygenic risk score (PRS) utilising data provided by the UK Biobank, and investigated the modification effect of genetic susceptibility. RESULTS During a median follow-up period of 11.9 years, 417 individuals developed schizophrenia (mean age 55.57 years, s.d. = 8.68; 45.6% female). Significant correlations were observed between long-term exposure to four air pollutants (PM2.5; PM10; nitrogen oxides, NOx; nitrogen dioxide, NO2) and the schizophrenia risk in each genetic risk group. Interactions between genetic factors and the pollutants NO2 and NOx had an effect on schizophrenia events. Compared with those with low PRS and low air pollution, participants with high PRS and high air pollution had the highest risk of incident schizophrenia (PM2.5: hazard ratio = 6.25 (95% CI 5.03-7.76); PM10: hazard ratio = 7.38 (95% CI 5.86-9.29); NO2: hazard ratio = 6.31 (95% CI 5.02-7.93); NOx: hazard ratio = 6.62 (95% CI 5.24-8.37)). CONCLUSIONS Long-term exposure to air pollutants was positively related to the schizophrenia risk. Furthermore, high genetic susceptibility could increase the effect of NO2 and NOx on schizophrenia risk.
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Affiliation(s)
- Run Liu
- Key Laboratory of Environment and Health, Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dankang Li
- Key Laboratory of Environment and Health, Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yudiyang Ma
- Key Laboratory of Environment and Health, Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lingxi Tang
- Key Laboratory of Environment and Health, Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiqi Chen
- Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China; and Hunan Key Laboratory of Tumor Models and Individualized Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yaohua Tian
- Key Laboratory of Environment and Health, Ministry of Education, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; State Key Laboratory of Environmental Health (Incubating), School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; and Department of Maternal and Child Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Bai L, Wang K, Liu D, Wu S. Potential Early Effect Biomarkers for Ambient Air Pollution Related Mental Disorders. TOXICS 2024; 12:454. [PMID: 39058106 PMCID: PMC11280925 DOI: 10.3390/toxics12070454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 06/18/2024] [Accepted: 06/21/2024] [Indexed: 07/28/2024]
Abstract
Air pollution is one of the greatest environmental risks to health, with 99% of the world's population living where the World Health Organization's air quality guidelines were not met. In addition to the respiratory and cardiovascular systems, the brain is another potential target of air pollution. Population- and experiment-based studies have shown that air pollution may affect mental health through direct or indirect biological pathways. The evidence for mental hazards associated with air pollution has been well documented. However, previous reviews mainly focused on epidemiological associations of air pollution with some specific mental disorders or possible biological mechanisms. A systematic review is absent for early effect biomarkers for characterizing mental health hazards associated with ambient air pollution, which can be used for early warning of related mental disorders and identifying susceptible populations at high risk. This review summarizes possible biomarkers involved in oxidative stress, inflammation, and epigenetic changes linking air pollution and mental disorders, as well as genetic susceptibility biomarkers. These biomarkers may provide a better understanding of air pollution's adverse effects on mental disorders and provide future research direction in this arena.
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Affiliation(s)
- Lijun Bai
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, 76 Yanta West Road, Yanta District, Xi’an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi’an Jiaotong University), Ministry of Education, Xi’an 710061, China
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an 710061, China
- Key Laboratory of Trace Elements and Endemic Diseases in Ministry of Health, Xi’an 710061, China
| | - Kai Wang
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, 76 Yanta West Road, Yanta District, Xi’an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi’an Jiaotong University), Ministry of Education, Xi’an 710061, China
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an 710061, China
- Key Laboratory of Trace Elements and Endemic Diseases in Ministry of Health, Xi’an 710061, China
| | - Dandan Liu
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, 76 Yanta West Road, Yanta District, Xi’an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi’an Jiaotong University), Ministry of Education, Xi’an 710061, China
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an 710061, China
- Key Laboratory of Trace Elements and Endemic Diseases in Ministry of Health, Xi’an 710061, China
| | - Shaowei Wu
- Department of Occupational and Environmental Health, School of Public Health, Xi’an Jiaotong University Health Science Center, 76 Yanta West Road, Yanta District, Xi’an 710061, China
- Key Laboratory of Environment and Genes Related to Diseases (Xi’an Jiaotong University), Ministry of Education, Xi’an 710061, China
- Key Laboratory for Disease Prevention and Control and Health Promotion of Shaanxi Province, Xi’an 710061, China
- Key Laboratory of Trace Elements and Endemic Diseases in Ministry of Health, Xi’an 710061, China
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Radua J, De Prisco M, Oliva V, Fico G, Vieta E, Fusar-Poli P. Impact of air pollution and climate change on mental health outcomes: an umbrella review of global evidence. World Psychiatry 2024; 23:244-256. [PMID: 38727076 PMCID: PMC11083864 DOI: 10.1002/wps.21219] [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: 05/13/2024] Open
Abstract
The impact of air pollution and climate change on mental health has recently raised strong concerns. However, a comprehensive overview analyzing the existing evidence while addressing relevant biases is lacking. This umbrella review systematically searched the PubMed/Medline, Scopus and PsycINFO databases (up to June 26, 2023) for any systematic review with meta-analysis investigating the association of air pollution or climate change with mental health outcomes. We used the R metaumbrella package to calculate and stratify the credibility of the evidence according to criteria (i.e., convincing, highly suggestive, suggestive, or weak) that address several biases, complemented by sensitivity analyses. We included 32 systematic reviews with meta-analysis that examined 284 individual studies and 237 associations of exposures to air pollution or climate change hazards and mental health outcomes. Most associations (n=195, 82.3%) involved air pollution, while the rest (n=42, 17.7%) regarded climate change hazards (mostly focusing on temperature: n=35, 14.8%). Mental health outcomes in most associations (n=185, 78.1%) involved mental disorders, followed by suicidal behavior (n=29, 12.4%), access to mental health care services (n=9, 3.7%), mental disorders-related symptomatology (n=8, 3.3%), and multiple categories together (n=6, 2.5%). Twelve associations (5.0%) achieved convincing (class I) or highly suggestive (class II) evidence. Regarding exposures to air pollution, there was convincing (class I) evidence for the association between long-term exposure to solvents and a higher incidence of dementia or cognitive impairment (odds ratio, OR=1.139), and highly suggestive (class II) evidence for the association between long-term exposure to some pollutants and higher risk for cognitive disorders (higher incidence of dementia with high vs. low levels of carbon monoxide, CO: OR=1.587; higher incidence of vascular dementia per 1 μg/m3 increase of nitrogen oxides, NOx: hazard ratio, HR=1.004). There was also highly suggestive (class II) evidence for the association between exposure to airborne particulate matter with diameter ≤10 μm (PM10) during the second trimester of pregnancy and the incidence of post-partum depression (OR=1.023 per 1 μg/m3 increase); and for the association between short-term exposure to sulfur dioxide (SO2) and schizophrenia relapse (risk ratio, RR=1.005 and 1.004 per 1 μg/m3 increase, respectively 5 and 7 days after exposure). Regarding climate change hazards, there was highly suggestive (class II) evidence for the association between short-term exposure to increased temperature and suicide- or mental disorders-related mortality (RR=1.024), suicidal behavior (RR=1.012), and hospital access (i.e., hospitalization or emergency department visits) due to suicidal behavior or mental disorders (RR=1.011) or mental disorders only (RR=1.009) (RR values per 1°C increase). There was also highly suggestive (class II) evidence for the association between short-term exposure to increased apparent temperature (i.e., the temperature equivalent perceived by humans) and suicidal behavior (RR=1.01 per 1°C increase). Finally, there was highly suggestive (class II) evidence for the association between the temporal proximity of cyclone exposure and severity of symptoms of post-traumatic stress disorder (r=0.275). Although most of the above associations were small in magnitude, they extend to the entire world population, and are therefore likely to have a substantial impact. This umbrella review classifies and quantifies for the first time the global negative impacts that air pollution and climate change can exert on mental health, identifying evidence-based targets that can inform future research and population health actions.
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Affiliation(s)
- Joaquim Radua
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
| | - Michele De Prisco
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Vincenzo Oliva
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Giovanna Fico
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Eduard Vieta
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Department of Medicine, Institute of Neuroscience, University of Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), Instituto de Salud Carlos III, Madrid, Spain
- Bipolar and Depressive Disorders Unit, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Paolo Fusar-Poli
- Early Psychosis: Interventions and Clinical-detection (EPIC) Lab, Department of Psychosis Studies, King's College London, London, UK
- Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
- Outreach and Support in South-London (OASIS) service, South London and Maudlsey NHS Foundation Trust, London, UK
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University Munich, Munich, Germany
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Cui Z, Ma Y, Yu Y, Li N, Wang J, Wang A, Tan Q. Short-term exposure to ambient fine particulate pollution aggravates ventilator-associated pneumonia in pediatric intensive care patients undergoing cardiovascular surgeries. Environ Health 2023; 22:39. [PMID: 37101281 PMCID: PMC10132412 DOI: 10.1186/s12940-023-00991-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/19/2023] [Indexed: 05/04/2023]
Abstract
BACKGROUND Ambient air pollutants can be hazardous to human health, especially for vulnerable children. The impact of ambient air pollutant exposure before and during intensive care unit (ICU) stays on the development of ventilator-associated pneumonia (VAP) in critically ill children has not been established. We aimed to determine the correlations between short-term exposures to ambient fine particulate matter (PM2.5) and VAP in pediatric cardiac surgery patients in the ICU, and explore the effect of delayed exposure. METHODS The medical record of 1755 child patients requiring artificial ventilation in the ICU between December 2013 to December 2020, were analyzed. The daily average concentrations of particulate matters (PM2.5 and PM10), sulfur dioxide (SO2), and ozone (O3) were calculated from public data. Interactions between these pollutants and VAP were simulated with the distributed lag non-linear model. RESULTS Three hundred forty-eight cases (19.829%) of VAP were identified in this study, while the average concentrations of PM2.5, PM10, O3 and SO2 were 58, 118, 98 and 26 μg/m3, respectively. Exposure to increased levels of PM2.5 two days prior (lag 2-day) to VAP diagnosis is significantly correlated with an enhanced risk for VAP development. Even a slight increase of 10 μg/m3 in PM2.5 can translate to a 5.4% increase in VAP incidence (95% CI: 1.4%-9.5%) while the VAP incidence increased to 11.1% (95%CI: 4.5-19.5%) when PM2.5 concentration is well below the National Ambient Air Quality standard (NAAQS) of 50 μg/m3. The association was more pronounced in those aged below 3-months, with low body mass index or suffered from pulmonary arterial hypertension. CONCLUSION Short-term PM2.5 exposure is a significant risk for development of VAP in pediatric patients. This risk is present even with PM2.5 levels below the NAAQS. Ambient PM2.5 may represent a previously unrecognized risk factor for pneumonia and the current environmental pollution standards need to be reevaluated to consider susceptible populations. TRIAL REGISTRATION The trial was registered with the National Clinical Trial Center: The correlation between ambient air pollution and the complications in ICU underwent cardiac surgery. TRIAL REGISTRATION NUMBER ChiCTR2000030507. Date of registration: March 5, 2020. URL of trial registry record: http://www.chictr.org.cn/index.aspx .
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Affiliation(s)
- Zhaomei Cui
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Yingying Ma
- Medical Engineering Department, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Yuanyuan Yu
- Data Science Institute, Shandong University, Jinan, Shandong China
| | - Na Li
- Department of Gynecology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong China
| | - Jun Wang
- Department of Pharmacy, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Anbiao Wang
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 9677 Jingshi Road, Jinan, 250021 China
| | - Qi Tan
- Intensive Care Unit (ICU), Department of Cardiac Surgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, No. 9677 Jingshi Road, Jinan, 250021 China
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Dabiri M, Dehghani Firouzabadi F, Yang K, Barker PB, Lee RR, Yousem DM. Neuroimaging in schizophrenia: A review article. Front Neurosci 2022; 16:1042814. [PMID: 36458043 PMCID: PMC9706110 DOI: 10.3389/fnins.2022.1042814] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
In this review article we have consolidated the imaging literature of patients with schizophrenia across the full spectrum of modalities in radiology including computed tomography (CT), morphologic magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), magnetic resonance spectroscopy (MRS), positron emission tomography (PET), and magnetoencephalography (MEG). We look at the impact of various subtypes of schizophrenia on imaging findings and the changes that occur with medical and transcranial magnetic stimulation (TMS) therapy. Our goal was a comprehensive multimodality summary of the findings of state-of-the-art imaging in untreated and treated patients with schizophrenia. Clinical imaging in schizophrenia is used to exclude structural lesions which may produce symptoms that may mimic those of patients with schizophrenia. Nonetheless one finds global volume loss in the brains of patients with schizophrenia with associated increased cerebrospinal fluid (CSF) volume and decreased gray matter volume. These features may be influenced by the duration of disease and or medication use. For functional studies, be they fluorodeoxyglucose positron emission tomography (FDG PET), rs-fMRI, task-based fMRI, diffusion tensor imaging (DTI) or MEG there generally is hypoactivation and disconnection between brain regions. However, these findings may vary depending upon the negative or positive symptomatology manifested in the patients. MR spectroscopy generally shows low N-acetylaspartate from neuronal loss and low glutamine (a neuroexcitatory marker) but glutathione may be elevated, particularly in non-treatment responders. The literature in schizophrenia is difficult to evaluate because age, gender, symptomatology, comorbidities, therapy use, disease duration, substance abuse, and coexisting other psychiatric disorders have not been adequately controlled for, even in large studies and meta-analyses.
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Affiliation(s)
- Mona Dabiri
- Department of Radiology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Kun Yang
- Department of Psychiatry, Molecular Psychiatry Program, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Peter B. Barker
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institution, Baltimore, MD, United States
| | - Roland R. Lee
- Department of Radiology, UCSD/VA Medical Center, San Diego, CA, United States
| | - David M. Yousem
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Medical Institution, Baltimore, MD, United States
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