[Schizophrenia and culture: reality and perspectives based on the Tunisian experience]

TLR4 Polymorphisms (T399I/D299G) Association with Schizophrenia and Bipolar Disorder in a Tunisian Population

Immune dysregulation has been widely described in the pathophysiology of schizophrenia (SCZ) and bipolar disorder (BD). Particularly, TLR4-altered activation was proposed as one of the underlying processes of psychosis onset. Since TLR4 activation was altered by T399I and D299G polymorphisms, we hypothesized that those variants could present common genetic factors of SCZ and BD. A total of 293 healthy volunteers and 335 psychotic patients were genotyped using PCR-RFLP. Genotype, allele, and haplotype distribution between controls and patients were evaluated according to clinical parameters. Statistical analyses were adjusted by logistic regression. In dominant model, T399I CT + TT and allele frequency were significantly higher in controls compared to psychotic population (p = 0.004, p = 0.002, respectively), SCZ (p = 0.02, p = 0.01, respectively), and BD (p = 0.03, p = 0.02, respectively). Similarly, D299G AG + GG and allele frequency were significantly higher in controls compared to psychotic population (p = 0.04, p = 0.04, respectively) and SCZ (p = 0.04, p = 0.03, respectively). T399I CT + TT and T allele were overrepresented in controls compared to paranoid subgroup (Padjusted = 0.04, p = 0.04, respectively) and type I BD (p = 0.04). Moreover, T399I and D299G were less prevalent in SCZ late-onset age (p = 0.03, p = 0.02, respectively). TA haplotype was associated with protection from psychoses (p = 0.02) and particularly from schizophrenia (p = 0.04). In conclusion, TLR4 polymorphisms could present a preventive genetic background against psychoses onset in a Tunisian population. While T399I could be associated with protection against SCZ and BD, presenting an overlapping genetic factor between those psychoses, D299G was suggested to be associated with protection only from schizophrenia.

A Preventive Role of RANTES Genetic Variation against Undifferentiated Schizophrenia

AIM

Due to conflicting data from relevant studies, evidence for chemokine alterations in the pathophysiology of schizophrenia (Scz) remains inconclusive. Thus, we aimed to investigate the impact of rs2107538, rs2280788, and rs2280789 polymorphisms in CCL5 gene, as well as rs333 within CCR5 gene and the development of Scz in a Tunisian cohort.

METHODS

We performed a case-control study composed of 200 patients and 200 controls using RFLP-PCR.

RESULTS

Among the analyzed polymorphisms, only rs2107538 imparted protection against Scz and more specifically to male sex. This protective effect remained valid for the undifferentiated form. Moreover, this SNP had an impact on patients' symptomatology. When focusing on haplotypes, we noticed that the rs2107538-rs2280788-rs2280789 ACT genetic combination, with only one mutated allele rs2107538A, displayed reduced frequency in both Scz (as a whole group) and undifferentiated subtype. The haplotype distribution profile implies that the A allele at rs2107538 could induce a protective effect by increasing RANTES production.

CONCLUSION

Additional independent analyses are required to corroborate these findings and elucidate the functional implications of the discovered preventing genotypes and haplotypes in Scz.

Association between TLR2 polymorphisms (- 196-174 Ins/Del, R677W, R753Q, and P631H) and schizophrenia in a Tunisian population

Since immune dysregulation has been well studied in schizophrenia pathophysiology, recent studies showed a potent role of TLR2 in neuroinflammation process underlying schizophrenia pathogenesis. However, the genetic predisposition is still unclear. Thus, we hypothesized that TLR2 polymorphisms - 196-174 Ins/Del (rs111200466), R753Q (rs5743708), R677W (rs121917864), and P631H (rs5743704) could be involved in schizophrenia predisposition. A case-control study was performed on a Tunisian population composed of 250 healthy controls and 250 patients genotyped by PCR-RFLP. Genotype and allele distribution were evaluated with sex, schizophrenia subtypes, and other clinical features. We also assessed a haplotype analysis for TLR2 polymorphisms with schizophrenia. Our results showed higher ins/del genotype frequency in healthy women compared to patients (p = 0.006; OR = 0.2). In the other hand, logistic regression showed higher ins/del genotype frequency in controls compared to paranoid patients (p = 0.05; OR = 0.48, adjusted). Frequencies of CT and T allele of R677W were significantly higher in patients compared to controls (p < 10^-4, OR = 10.39; p < 10^-4, OR = 4, adjusted, respectively). R753Q polymorphism was exclusively detected in patients (GA + AA = 2.5%) particularly in men with disorganized subtype. P631H did not show any association with schizophrenia. Finally, haplotype analysis showed that InsGTC and delGTC were associated with higher risk of schizophrenia (p = 0.0001, OR = 8.58; p = 0.04, OR = 5.01, respectively). In the Tunisian population, our results suggested that TLR2 R677W could be associated with susceptibility for schizophrenia, while - 196-174 Ins/Del suggested a trend of protection in women. Otherwise, R753Q could have an effect on schizophrenia especially for disorganized subgroup.

Inteurleukin-8 gene variations and the susceptibility to schizophrenia

The relevance of Interleukin-8 (IL-8) cytokine alteration in the peripheral and central system has been widely shown in psychosis while variation in the IL-8 gene remains largely unexplored and to the best of our knowledge, IL-8 polymorphisms have never been specifically targeted in Schizophrenia (Scz). Thus, we set out to search a potential correlation between rs4073, rs2227306 and rs1126647 polymorphisms in IL-8 gene and the development of Scz in a sample of the Tunisian population in a candidate gene approach. Targeted polymorphisms were analysed in 206 patients and 195 controls using PCR-RFLP method. Among all analysed polymorphisms, only rs1126647 showed a significant risk for Scz. After stratification analysis, we noted a significant association of TT genotype and T allele at rs1126647 with paranoid form, and more specifically with female sex. We find that the rare haplotypes at rs4073-rs2227306-rs1126647 of TTT, ACT and TCT, each containing the risk allele rs1126647T, were associated with increased risk for paranoid Scz while only the TCT combination constituted a risk factor for Scz more generally. Our findings support that IL-8 gene may be involved in susceptibility to Scz but this still preliminary and needs to be strengthened by further independent analyses.

Haplotypes of TNFα/β Genes Associated with Sex-Specific Paranoid Schizophrenic Risk in Tunisian Population

Several medical research findings have announced a strong association between the biology of cytokines and various brain activities. Since growing evidences suggest the crucial and complex role of the tumor necrosis factor in the CNS, we have hypothesized that functional genetic variants of the LTA and TNFA genes (LTA +252A/G (rs909253) and TNFA -857C/T (rs1799724) and TNFA -238G/A (rs361525)) may be involved in the predisposition to schizophrenia. This research is based on a case-control study. The RFLP-PCR genotyping was conducted on a Tunisian population composed of 208 patients and 208 controls. We found a strong significant overrepresentation of the minor alleles (G, T, and A, respectively) in all patients compared with controls (p = 0.003, OR = 1.55; p = 0.005, OR = 1.78; and p = 0.0001, OR = 1.74, respectively). This correlation was confirmed for male but not for female patients. Interestingly, the frequencies of the minor alleles were significantly more common among patients with paranoid schizophrenia when compared with controls (p = 0.003, OR = 1.75; p = 5 · 10^-6, OR = 3.04; and p = 4 · 10^-6, OR = 2.35, respectively). This potential association was confirmed by a logistic binary regression analysis only for the development of the paranoid form of schizophrenia (p = 0.001/OR = 2.6; p = 0.0002/OR = 3.2; and p = 0.0004/OR = 3.1, respectively) and remained not significant for the other subtypes. Moreover, our study showed an important association between GCA haplotype and the development of this pathological form (p = 10^-4, OR = 3.71). In conclusion, our results proved a significant association between the three polymorphisms and paranoid schizophrenia, at least in the Tunisian population, suggesting a substantially increased risk for paranoid schizophrenia with dominant inheritance of these three minor alleles.

[Symptomatic remission and its relationship to social functioning in Tunisian out-patients with schizophrenia]

INTRODUCTION

The concept of symptomatic and functional remission represents an important challenge in the care of the mentally ill, particularly in patients with schizophrenia. Operational criteria for symptomatic remission in schizophrenia have been proposed by Andreasen et al. (2005). Over the last decade, these criteria have been widely validated; however few studies have been conducted outside developed countries. Moreover, the association of symptomatic remission with functional outcome has not yet been established in developing countries including Tunisia, as there may be variability in the social and familial environment.

OBJECTIVES

To determine the frequency and associated factors of symptomatic remission in a sample of Tunisian out-patients with schizophrenia and to explore the relationship between symptomatic remission and some indicators of social functioning.

METHODS

A cross-sectional study was carried-out on 115 out-patients with schizophrenia (87 males, 28 females, mean age=37.56±10.2 years) in the psychiatry department of the university hospital in Monastir (Tunisia). Nearly all of the patients (98.26%) had been hospitalized at least once in a psychiatric unit. The last hospitalization dated back to 39 months on average (range=6 months to 16 years). Symptomatic remission was assessed by the eight core items of the positive and negative syndrome scale (PANSS). These are the items P1 "Delusions"; P3 "Hallucinatory behavior" and G9 "Unusual thought content" for the positive dimension, the items P2 "Conceptual disorganization" and G5 "Mannerism and disorders of posture" for the disorganization dimension and the items N1 "Blunted affect", N4 "Social withdrawal" and N6 "Lack of spontaneity and flow of conversation" for the negative dimension. A score of mild or less on all eight-core symptoms constitutes symptomatic remission. This symptom level should have been maintained for six months. The social functioning was assessed by the Social and Occupational Functioning Assessment Scale (SOFAS) and the Social Autonomy Scale (SAS) exploring personal care, management of daily life, resource management, the relationship with the outside and the emotional life and relationships social. A multivariate analysis using a binary logistic regression was conducted with as a dependent variable "symptomatic remission" and as explanatory variables the associated variables with symptomatic remission in bivariate analysis with age and gender.

RESULTS

The symptomatic remission was observed in 50.4% of patients. The items corresponding to positive dimension (P1, P3 and G9) and the item P2 "conceptual disorganization" had a better predictive value of symptomatic remission. After multivariate analysis, the associated factors of symptomatic remission were the acute of onset (P=0.026), the low score of negative symptoms during the last hospitalization (P=0.017) and the episodic course (P<0.0001). However, age or gender of the patients, educational or socioeconomic level, psychiatric family history, age of onset, duration of untreated psychosis, number and duration of previous hospitalizations, antipsychotic treatment dosage were not associated with symptomatic remission in our sample. The mean score of the SOFAS was 48.47±14.44, and the mean score of the SAS was 56.6±16.84. A significant association was shown between the SOFAS score and the symptomatic remission (P<0.0001) and between the SAS score and the symptomatic remission (P<0.0001). Moreover, a significant association was found between symptomatic remission and occupational activity (P=0.03).

CONCLUSION

The frequency of symptomatic remission according the PANSS criteria in our sample is above the average of the reported rates in literature (30 to 60%). This can be explained by the frequency of symptomatic remission in outpatient versus inpatients, or in relation to the notion of a more favorable course of schizophrenia in developing countries, although this notion is controversial. Remitter patients had significantly an acute onset of disorders, a low score of negative symptoms during the last hospitalization and an episodic course. They also showed a significant trend for better social functioning. In fact, a significant association was shown in our sample between symptomatic remission and social functioning. These results suggest that the concept of remission has important implications for the treatment of patients with schizophrenia.

[Tunisian mothers' beliefs about their child's first psychotic episode]

INTRODUCTION

Initiating psychiatric treatment depends on several factors including clinical, personal, familial and economic factors. In the case of a first psychotic episode in an adolescent, parents, especially mothers, have a critical role in initiating psychiatric treatment for their child.

OBJECTIVE

In this study, we investigated mothers' beliefs about their child's first psychotic episode.

METHODS

Participants were adolescents consulting the department of Child and Adolescent Psychiatry of the Razi hospital in Tunisia. They were aged from 12 to 19 years at the onset of their medical follow-up. Their diagnoses were schizophrenia, schizoaffective disorder and schizophreniform disorder according to DSM-IV. A questionnaire was submitted to patients' mothers after their approval. It was divided into two parts. The first part was used to collect information on socio-demographic and clinical characteristics of the mothers and their children. The second part was composed of the following four questions in Tunisian dialect: (1) what did you think was the matter when you first noticed psychotic symptoms in your child? (2) what was the main reason for which you thought psychiatric treatment was necessary? (3) what obstacles did you perceive in initiating psychiatric treatment? (4) do you have any advice or suggestions for caregivers on how they could facilitate an early start of treatment?

RESULTS

Twenty-two mothers were included. The mean age of the mothers at onset of the follow-up of their child was 42 years (SD: 4.81). Ten mothers had never been schooled, five had primary school level, four had secondary school level, three had bachelor's degree and two had a diploma of doctorate; 63.6% of the mothers were housewives. The mean age of patients was 13.77 years at the start of their medical follow-up (SD= ± 2.14). Most of the patients were male (14 males for eight girls). Most patients were diagnosed as having schizophrenia (91%); 4.5% were diagnosed with schizoaffective disorder and 4.5% with schizophreniform disorder. The duration of untreated psychosis (DUP) was 11.5 months. Longer duration of untreated psychosis was associated with male gender (P=0.008). A significant relationship was also found between long DUP and stigmatization of mental hospital and psychiatry (respectively P=0.04 and P=0.05). Most of the mothers did not think that their child initially suffered from a psychotic disorder. In 63.3%, the cause of the child's symptomatology was attributed to spirit possession. The others reasons for seeking psychiatric treatment were: behavioral disorder in 77.3%, inefficacity of traditional practices in 54.5%, and patient refusal (40.9%). Stigmatization of the Razi hospital, the unique psychiatric hospital in the country, and of psychiatry in general were evoked by mothers as the main obstacles in initiating psychiatric treatment in more than half of the cases (70%). Others obstacles were: fear of side effects of psychiatric treatment (50%), patient refusal (40.9%), inaccessibility to psychiatric services (31.8%) and fear of an addiction to psychotropic agents (31.8%). Thirty-six percent of mothers underlined the need to consult in the occurrence of school difficulties or any change in the child's behavior; 27% proposed educational and anti-stigmatizing campaigns about the signs of early psychosis through radio, newspapers, cinema, and TV media advertisements. Making teachers and educators sensitive to psychosis was proposed by 13.6% of mothers; 9.1% thought that diagnostic skills should be improved in general practitioners.

CONCLUSION

Knowledge of attitudes of mothers towards the illness of their child prior to psychiatric treatment and towards the start of treatment is essential for the development of interventions for reducing duration of untreated psychosis.

The abilities of improved schizophrenia patients to work and live independently in the community: a 10-year long-term outcome study from Mumbai, India

BACKGROUND

The outcome of first episode schizophrenia has several determinants. Socioecological factors, particularly living conditions, migration, community and culture, not only affect the level of risk but also the outcome. Mega cities around the world show a unique socioecological condition that has several challenges for mental health. The present study reports on the long-term status of patients with schizophrenia in such a mega city: Mumbai, India.

AIM

This study aims to reveal the long-term outcome of patients suffering from schizophrenia with special reference to clinical symptoms and social functioning.

METHODS

The cohort for this study was drawn from a 10-year follow-up of first episode schizophrenia. Patients having completed 10 years of consistent treatment after first hospitalisation were assessed on psychopathological and recovery criteria. Clinical as well as social parameters of recovery were evaluated. Descriptive statistics with 95% confidence intervals are provided.

RESULTS

Of 200 patients recruited at the beginning of this study, 122 patients (61%) were present in the city of Mumbai at the end of 10-year follow-up study period. Among 122 available patients, 101 patients (50.5%) were included in the assessment at the end of 10-year follow-up study period, 6 patients (3.0%) were excluded from the study due to changed diagnosis, and 15 patients (7.5%) were excluded due to admission into long-term care facilities. This indicates that 107 out of 122 available patients (87.7%) were living in the community with their families. Out of 101 (50.5%) patients assessed at the end of 10 years, 61 patients (30.5%) showed improved recovery on the Clinical Global Impression Scale, 40 patients (20%) revealed no improvement in the recovery, 43 patients (72.9%) were able to live independently, and 24 patients (40%) were able to find employment.

CONCLUSION

With 10 years of treatment, the recovery rate among schizophrenia patients in Mumbai was 30.5%. Among the patients, 87.7% of patients lived in the community, 72.9% of patients lived independently, and 40% of patients obtained employment. However, 60% of patients were unable to return to work, which highlights the need for continued monitoring and support to prevent the deterioration of health in these patients. It is likely that socioecological factors have played a role in this outcome.