Negative symptoms in schizophrenia: a review

A systematic review and synthesis of 489 studies investigating treatments for negative symptoms in the schizophrenia spectrum: Trial designs, demographics and clinical characteristics

Negative symptoms in schizophrenia spectrum are associated with minimal treatment responses. The search for effective treatments is potentially hampered by heterogenous study-designs and sample characteristics depending on the intervention category. This PRISMA-compliant systematic review/synthesis aims to describe the literature on negative symptoms interventions for schizophrenia spectrum disorders by comparing 12 study design, demographical and clinical variables in different intervention categories: antipsychotics (AP), other pharmacological agents (OPA), brain stimulation (BS), psychological/psychosocial (PSI), lifestyle (LS), mixed interventions. Kruskal-Wallis and Chi-square tests measured differences between intervention-groups. Out of 19,935 articles, 489 (AP=149/OPA=187/BS=49/PSI=79/LS=19/mixed=6) were selected for data extraction. Concerning study designs, AP had the largest average arm size (mean ± SD=91.1 ± 122.8participants), OPA the highest double/triple-blinding (97.9 %) rates, PSI the longest follow-up (26.7 ± 21.8weeks). Age/gender demographical differences were significant but of negligible magnitude. OPA illness duration (14.8 ± 9.0years) was longer compared to AP (11.4 ± 6.7years). Positive and Negative Syndrome Scale (PANSS) negative scores were milder in PSI (18.6 ± 6.9) compared to AP/OPA/BS (23.8 ± 6.4/23.4 ± 4.9/24.2 ± 9.2). PANSS total scores were worse in AP (83.6 ± 18.2) than in OPA/BS/PSI (77.1 ± 20.5/75.5 ± 14.7/67.0 ± 23.3). The same was true for dropout rates (AP=25.5 %, OPA/BS/PSI=14.3/9.7/14.5 %). Prevalent treatment as usual was "none" for AP (36.7 %) and "antipsychotic" for other categories (42.3-82.8 %). Implementing cross-over, factorial or multi-arm designs may increase the comparability between studies investigating different intervention categories. Concerning clinical differences, reporting individual treatments at baseline and clinical severity, evaluating cognitive profiles and considering patients' perspectives will allow to better understand the efficacy of the available treatments and develop tailored interventions.

Brain Structural Alterations Underlying Mood-Related Deficits in Schizophrenia

Background/Objectives: Schizophrenia (SZ) is a complex psychiatric disorder characterized by neurodegenerative processes, but the structural brain alterations associated with its progression remain poorly understood. This study investigated structural brain changes in SZ, particularly in the fronto-temporal and limbic regions, and explored their relationship with symptom severity, with a focus on mood- and emotion-related symptoms. Methods: We analyzed structural MRI data from 74 SZ patients and 91 healthy controls (HCs) using voxel-based morphometry (VBM) to compare whole-brain grey matter volumes (GMVs). The analysis focused on the fronto-temporal and limbic regions, and correlations between GMV and symptom severity were assessed using the Positive and Negative Syndrome Scale (PANSS) and the Generalized Psychopathology (GP) scale. Results: SZ patients exhibited significant reductions in GMV in the fronto-temporal and limbic regions, including the dorsolateral prefrontal cortex (dlPFC) and the temporal pole, compared to HCs. Notably, a significant positive association was found between GMV in the right inferior temporal gyrus (ITG) and the severity of generalized psychopathology, as well as with anxiety, depression, mannerisms, and unusual thought content. Further post hoc analysis identified a specific cluster of mood-related symptoms contributing to the GP scale, which correlated with GMV changes in the right ITG. Conclusions: Our findings provide new evidence of structural brain alterations in SZ, particularly in the fronto-temporal and limbic regions, suggesting a progressive neurodegenerative pattern. The role of the right ITG in mood- and emotion-related symptoms requires further exploration, as it could offer insights into SZ pathophysiology and aid in distinguishing SZ from other mood-related disorders.

Impact of loneliness and living alone on negative symptoms in severe mental illness: An electronic health record data analysis

Important changes in symptom profiles occur early in the course of severe mental illness (SMI) after its clinical presentation. The emergence of negative symptoms is of particular concern for later function, and these may well have strong links with loneliness and poor social support which are also recognised to be common. However, the impact of loneliness and social isolation on symptoms and treatment outcomes remains unclear. To explore this, we conducted a retrospective observational analysis using data from electronic health records of a large mental health provider in London. Loneliness, living alone and symptoms of SMI were extracted using bespoke natural language processing algorithms. Symptoms were grouped into five domains: positive, negative, disorganised, manic, and catatonic, and were measured at diagnosis and 12 months following the initial SMI diagnosis. Loneliness and living alone were operationalised as binary variables, based on any recording during the follow-up period. A total of 8237 records were analysed. The prevalence of loneliness was 20.4 % and living alone 19.9 %, with only 6.8 % recorded with both. Recorded loneliness was associated with an increase in negative symptoms over the follow-up period, in models adjusted by sociodemographic variables and pharmacological treatment [OR 1.28 (1.11-1.48), p = 0.001], as was living alone to a weaker extent [OR 1.18 (1.02-1.36), p = 0.030]. No associations were found between either exposure variable and changes in symptoms from other domains. Given that negative symptoms are disabling and challenging to treat, these results highlight the importance of effective interventions to enhance social support in SMI over the early post-diagnostic period.

Dutch Validation of the Self-Evaluation of Negative Symptoms Scale (SNS)

BACKGROUND/OBJECTIVES

Negative symptoms in schizophrenia spectrum disorders are related to impaired social functioning and lower quality of life, making accurate assessment important. To date, most tools for assessing negative symptoms are observational, which can be influenced by the raters' experience and opinion. Self-rating scales, like the Self-Evaluation of Negative Symptoms (SNS), could complement observer ratings by adding information from the patient's perspective. Here, we aim to evaluate the psychometric properties of the Dutch translation of the SNS and the relationship between the SNS and functional outcomes.

METHODS

The SNS was added to the Pharmacotherapy Monitoring Outcome Survey (PHAMOUS)-protocol for adults with a DSM-5 classification of a disorder in the psychosis spectrum. Internal consistency was assessed by Cronbach's alpha. Confirmatory factor analysis (CFA) was used to evaluate the construct validity of the five subscales of the SNS. Correlational analyses were performed between the SNS and the Positive and Negative Syndrome Scale (PANSS), the Health of Nation Outcomes Scales (HoNOS), the Global Assessment of Functioning (GAF), Functional Remission tool (FR) and the Manchester Short Assessment of Quality of Life (ManSA).

RESULTS

A total of 247 patients participated in this study. Internal consistency was good (α = 0.87). CFA confirmed the five-factor structure of the SNS. The SNS was significantly correlated (all p < 0.001) with the PANSS positive (r = 0.31), PANSS negative (r = 0.33), HoNOS (r = 0.37), FR (r = 0.27) and the ManSA (r = -0.40).

CONCLUSIONS

The Dutch SNS shows good psychometric properties and is related to functional outcomes and quality of life. The SNS can be valuable in complementing current observational-based instruments, and future research may investigate whether the SNS can be used as a standalone measurement tool for the assessment of negative symptoms.

Prediction of Clinical Outcomes in Psychotic Disorders Using Artificial Intelligence Methods: A Scoping Review

BACKGROUND

Psychotic disorders are major psychiatric disorders that can impact multiple domains including physical, social, and psychological functioning within individuals with these conditions. Being able to better predict the outcomes of psychotic disorders will allow clinicians to identify illness subgroups and optimize treatment strategies in a timely manner.

OBJECTIVE

In this scoping review, we aimed to examine the accuracy of the use of artificial intelligence (AI) methods in predicting the clinical outcomes of patients with psychotic disorders as well as determine the relevant predictors of these outcomes.

METHODS

This review was guided by the PRISMA Guidelines for Scoping Reviews. Seven electronic databases were searched for relevant published articles in English until 1 February 2024.

RESULTS

Thirty articles were included in this review. These studies were mainly conducted in the West (63%) and Asia (37%) and published within the last 5 years (83.3%). The clinical outcomes included symptomatic improvements, illness course, and social functioning. The machine learning models utilized data from various sources including clinical, cognitive, and biological variables such as genetic, neuroimaging measures. In terms of main machine learning models used, the most common approaches were support vector machine, random forest, logistic regression, and linear regression models. No specific machine learning approach outperformed the other approaches consistently across the studies, and an overall range of predictive accuracy was observed with an AUC from 0.58 to 0.95. Specific predictors of clinical outcomes included demographic characteristics (gender, socioeconomic status, accommodation, education, and employment); social factors (activity level and interpersonal relationships); illness features (number of relapses, duration of relapses, hospitalization rates, cognitive impairments, and negative and disorganization symptoms); treatment (prescription of first-generation antipsychotics, high antipsychotic doses, clozapine, use of electroconvulsive therapy, and presence of metabolic syndrome); and structural and functional neuroimaging abnormalities, especially involving the temporal and frontal brain regions.

CONCLUSIONS

The current review highlights the potential and need to further refine AI and machine learning models in parsing out the complex interplay of specific variables that contribute to the clinical outcome prediction of psychotic disorders.

Reexamination of the relationships among neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in a sample of patients diagnosed with chronic schizophrenia and schizoaffective disorder

PURPOSE

This study proposed and evaluated a theoretical model for exploring the relationships between neurocognition, self-defeatist beliefs, experiential negative symptoms, and social functioning in individuals with chronic schizophrenia.

METHOD

The study recruited 229 individuals given a diagnosis of schizophrenia and schizoaffective disorders from outpatient clinics and the day ward of a mental health hospital. After informed consent was obtained, the participants underwent assessments using the backward digit span, the digit symbol, and measures of self-defeatist beliefs, experiential negative symptoms, and social functioning. A structural equation model was applied to assess the fitness of the hypothesized model, with indices such as the goodness-of-fit index, comparative fit index, root mean square error of approximation, and standardized root mean square residual being used for model evaluation.

RESULTS

The hypothesized model had an adequate fit. The study findings indicated that neurocognition might indirectly influence self-defeatist beliefs through its effect on experiential negative symptoms. Contrary to expectations, the study did not observe a direct influence of neurocognition, self-defeatist beliefs, or negative symptoms on social functioning. The revised model revealed the role of experiential negative symptoms in mediating the association between neurocognition and social functioning. However, self-defeatist beliefs did not significantly affect social functioning.

DISCUSSION

Before modifying negative thoughts, enhancement of self-awareness ability can help improve negative symptoms and thereby improve the performance of social functions. Future research should develop a hierarchical program of negative symptoms, from cognition rehabilitation to enhancement of self-awareness, and end with modifying maladaptive beliefs.

Effect of Computer-Assisted Cognitive Remediation Therapy on Cognition among Patients with Schizophrenia: A Pilot Randomized Controlled Trial

In schizophrenia, cognition is closely linked to social competence and influences long-term prognosis. Thus, treatment should target cognitive improvement to enhance the patient's societal adaptation. This study evaluated the effects of computer-assisted cognitive remediation therapy (CR) using RehaCom® on cognition in patients with schizophrenia. Thirty patients were randomized, with 15 assigned to the CR and treatment as usual (TAU) group and 15 to the TAU-alone group. Over 12 weeks, patients received CR twice weekly, including two computer sessions and one verbal session. The outcomes measured were cognition using the Brief Assessment of Cognition in Schizophrenia and Schizophrenia Cognition Rating Scale, intrinsic motivation using the Quality of Life Scale and Intrinsic Motivation Inventory, psychiatric symptoms using the Positive and Negative Syndrome Scale, negative symptoms using the Scale for the Assessment of Negative Symptoms, and functional level using the modified Global Assessment of Functioning scale for Functioning. The CR + TAU group demonstrated considerable improvements in cognition, intrinsic motivation, and functional level compared to the TAU-alone group. These findings indicate that the CR using RehaCom® enhances cognition and other outcomes in schizophrenia.

Effect of individualized occupational therapy on cognition among patients with schizophrenia: A randomized controlled trial

This study aimed to evaluate the feasibility and efficacy of individualized occupational therapy (IOT) plus group occupational therapy (GOT) as standard care for cognition compared to GOT alone, and to determine which IOT component has the greatest effect on cognitive outcome in patients with schizophrenia. This study was conducted at 14 clinical sites across Japan and enrolled recently hospitalized patients with schizophrenia. The IOT consisted of motivational interview, self-monitoring, individualized visits, craft activities, individualized psychoeducation, and discharge planning. Among the 68 patients who were randomized to the GOT + IOT group (n = 34) and GOT alone group (n = 34), 67 completed the trial (GOT + IOT group, n = 34; GOT alone group, n = 33). There were significant improvements in change from baseline to post-treatment between the groups in verbal memory, working memory, verbal fluency, attention, executive function domains, and the composite score of the Brief Assessment of Cognition in Schizophrenia (BACS). The BACS composite score was significantly associated with the number of craft activity sessions. The addition of IOT to GOT has a favorable feasibility profile and efficacy for cognition in schizophrenia. Craft activity is the most effective IOT component in improving cognition.

16S rRNA gene sequencing reveals altered gut microbiota in young adults with schizophrenia and prominent negative symptoms

BACKGROUND

Gut dysbiosis has been established as a characteristic of schizophrenia (SCH). However, the signatures regarding SCH patients with prominent negative symptoms (SCH-N) in young adults have been poorly elucidated.

METHODS

Stool samples were obtained from 30 young adults with SCH-N, 32 SCH patients with prominent positive symptoms (SCH-P) along with 36 healthy controls (HCs). Microbial diversity and composition were analyzed by 16S rRNA gene sequencing. Meanwhile, psychiatric symptoms were assessed by the positive and negative syndrome scale (PANSS).

RESULTS

There is a significant difference in β-diversity but not α-diversity indexes among the three groups. Moreover, we found a higher abundance of Fusobacteria and Proteobacteria phyla and a lower abundance of Firmicutes phyla in SCH-N when compared with HC. Besides, we identified a diagnostic potential panel comprising six genera (Coprococcus, Monoglobus, Prevotellaceae_NK3B31_group, Escherichia-Shigella, Dorea, and Butyricicoccus) that can distinguish SCH-N from HC (area under the curve = 0.939). However, the difference in microbial composition between the SCH-N and SCH-P is much less than that between SCH-N and the HC, and SCH-N and SCH-P cannot be effectively distinguished by gut microbiota.

CONCLUSION

The composition of gut microbiota was changed in the patients with SCH-N, which may help in further understanding of pathogenesis in young adults with SCH-N.

Integrating Subjective Recovery and Stigma Resistance in Individuals with Schizophrenia: A Narrative Review and Theoretical Integration

Stigmatised attitudes are known to be associated with negative outcomes in schizophrenia, yet there is little focus on the role of stigma in the recovery process. Attempts to develop interventions to reduce self-stigma in schizophrenia have not been found effective. This paper presents a theoretical integration based on a narrative review of the literature. PsycINFO, Medline and Embase databases were searched up to the 11th December 2023. Studies were included if they were: i) empirical studies using qualitative, quantitative or mixed methods studies investigating mental health stigma; ii) included participants based in the United Kingdom, fluent in English, between the ages of 16 and 70, meeting criteria for a schizophrenia spectrum diagnosis. Fourteen studies were included. In Part 1, we propose a novel theoretical model derived from a synthesis of service-user perspectives on the relationship between stigma and schizophrenia. Stigmatised attitudes were commonly perceived to be caused by a lack of education and further exacerbated by disinformation primarily through the media and cultural communities. Stigma led to negative self-perceptions, negative emotional responses, social isolation and increased symptom severity, ultimately acting as a barrier to recovery. In Part 2, we identify several factors that ameliorate the impact of stigma and promote clinical and subjective recovery among service-users: education, empowerment, self-efficacy, self-acceptance, hope and social support. We argue that the notion of stigma resistance may be helpful in developing new interventions aimed at promoting recovery in individuals with schizophrenia. Wider implications are discussed and recommendations for future research and practice are explored.

Reward anticipation-related neural activation following cued reinforcement in adults with psychotic psychopathology and biological relatives

BACKGROUND

Schizophrenia is associated with hypoactivation of reward sensitive brain areas during reward anticipation. However, it is unclear whether these neural functions are similarly impaired in other disorders with psychotic symptomatology or individuals with genetic liability for psychosis. If abnormalities in reward sensitive brain areas are shared across individuals with psychotic psychopathology and people with heightened genetic liability for psychosis, there may be a common neural basis for symptoms of diminished pleasure and motivation.

METHODS

We compared performance and neural activity in 123 people with a history of psychosis (PwP), 81 of their first-degree biological relatives, and 49 controls during a modified Monetary Incentive Delay task during fMRI.

RESULTS

PwP exhibited hypoactivation of the striatum and anterior insula (AI) during cueing of potential future rewards with each diagnostic group showing hypoactivations during reward anticipation compared to controls. Despite normative task performance, relatives demonstrated caudate activation intermediate between controls and PwP, nucleus accumbens activation more similar to PwP than controls, but putamen activation on par with controls. Across diagnostic groups of PwP there was less functional connectivity between bilateral caudate and several regions of the salience network (medial frontal gyrus, anterior cingulate, AI) during reward anticipation.

CONCLUSIONS

Findings implicate less activation and connectivity in reward processing brain regions across a spectrum of disorders involving psychotic psychopathology. Specifically, aberrations in striatal and insular activity during reward anticipation seen in schizophrenia are partially shared with other forms of psychotic psychopathology and associated with genetic liability for psychosis.

Efficacy of Low-dose Olanzapine in Combination with Sertraline on Negative Symptoms and Psychosocial Functioning in Schizophrenia: A Randomized Controlled Trial

BACKGROUND

Evidence for the efficacy of a low dose of olanzapine (OLA) in combination with antidepressants has been limited and without positive trials in first-episode (FE) patients with schizophrenia (SCH). This study aimed to compare the efficacy in treating negative and depressive symptoms between those FE patients with SCH treated with a combination of OLA plus sertraline and those treated with OLA monotherapy.

METHODS

One hundred and ninety-six first-episode and drug naïve patients with SCH were randomized to receive low-dose OLA (7.5-10 mg/day) combined with sertraline (50-100 mg/day) (OS group) or normal-dose OLA monotherapy (12.5-20 mg/day) (NO group). Clinical symptoms were evaluated by the Positive and Negative Syndrome Scale (PANSS), and the depressive symptoms were evaluated by the Hamilton Depression Scale (HAMD). Psychosocial functioning was assessed by the Personal and Social Performance Scale (PSP).

RESULTS

In the intent-to-treat efficacy analysis, the OS group had greater decreases in negative and depressive symptoms (pall < 0.01) and a greater increase in PSP total score compared with the NO group (p < 0.01). Moreover, reductions in HAMD total score and PANSS negative subscore and sex were associated with the improvements in psychosocial functioning from baseline to week 24, after controlling for baseline psychosocial function, age, and onset age.

CONCLUSION

This study demonstrates that low-dose OLA in combination with sertraline had clinically meaningful improvements not only in the negative and depressive symptoms but also in psychosocial functioning in patients with FE-SCH, while not affecting positive symptoms.

Treatment effects of adjunct group music therapy in inpatients with chronic schizophrenia: a systematic review

Introduction

Pharmacological treatment may be effective for treating positive symptoms of schizophrenia; no evidence of clinically significant effects on negative and cognitive symptoms, social and behavioral functioning. This review investigated treatment outcomes of multiple (at least four sessions in 4 weeks) group music therapy sessions adjunct to standard care in inpatients with chronic schizophrenia.

Methods

A systematic review search of five electronic medical and psychological databases conducted using keywords "music therapy" and "schizophrenia" up to December 2021. Screening was performed for published articles on any adjunct multiple group music therapy (four sessions in 4 weeks minimum) adjunct to "treatment as usual" for inpatients with "chronic" schizophrenia. All study outcomes were all included. Risk of bias of all studies was assessed.

Results

1160 articles were screened, and 13 randomized controlled trials (RCTs) with a total of 1,114 inpatients were included. Ten RCTs reported open group sessions with active structured music making (ASMM) combining passive music listening (PML) and/or active singing, playing instruments, and improvisations while three other studies applied PML only. Four studies reported significant outcomes for both positive and negative symptoms. Ten of the thirteen studies recorded significant improvements in negative symptoms, behavioral and social functioning. Lasting significant effects were found in a longitudinal RCT with 272 samples evaluated unguided pre-recorded PML as a coping method lasting up to six months and similar results found in another two longitudinal RCTs. Secondary outcomes measured cognition, mood, social interest and function, self-care ability, interpersonal relationships, and QoL all showed significant outcomes. The significance level for pre-post intervention and between-group measures ranged from p < 0.001 to p < 0.05. No negative effects were reported in any studies.

Conclusion

Evidence from this review suggests rehabilitation with adjunctive regular PML or combined ASMM in group settings may provide therapeutic engagement, contributing to improvements in social interest and participation. PML is low-cost and non-invasive therapy. Enhancing overall QoL as one type of psychosocial therapy. More rigorous longitudinal studies with larger sample sizes are needed to investigate whether regular long-term individual PML and active group music therapy have the same significant treatment effects as coping and rehabilitation strategies.

A Systematic Review and Meta-Analysis of the Association Between Psychopathology and Social Functioning in Schizophrenia

BACKGROUND

Impaired social functioning is a major, but under-elucidated area of schizophrenia. It's typically understood as consequential to, eg, negative symptoms, but meta-analyses on the subject have not examined psychopathology in a broader perspective and there's severe heterogeneity in outcome measures. To enhance functional recovery from schizophrenia, a more comprehensive understanding of the nature of social functioning in schizophrenia is needed.

STUDY DESIGN

In this systematic review and meta-analysis, we searched PubMed, PsycInfo, and Ovid Embase for studies providing an association between psychopathology and social functioning. Meta-analyses of the regression and correlation coefficients were performed to explore associations between social functioning and psychopathology, as well as associations between their subdomains.

STUDY RESULTS

Thirty-six studies with a total of 4742 patients were included. Overall social functioning was associated with overall psychopathology (95% CI [-0.63; -0.37]), positive symptoms (95% CI [-0.39; -0.25]), negative symptoms (95% CI [-0.61; -0.42]), disorganized symptoms (95% CI [-0.54; -0.14]), depressive symptoms (95% CI [-0.33; -0.11]), and general psychopathology (95% CI [-0.60; -0.43]). There was significant heterogeneity in the results, with I2 ranging from 52% to 92%.

CONCLUSIONS

This is the first systematic review and meta-analysis to comprehensively examine associations between psychopathology and social functioning. The finding that all psychopathological subdomains seem to correlate with social functioning challenges the view that impaired social functioning in schizophrenia is mainly a result of negative symptoms. In line with classical psychopathological literature on schizophrenia, it may be more appropriate to consider impaired social functioning as a manifestation of the disorder itself.

Dimensional characteristics of persistent negative symptoms in schizophrenia and their relationships with schizotypy in first-degree relatives

PURPOSE OF THE ARTICLE

Schizophrenia with persistent negative symptoms (PNS) may have different characteristics regarding negative symptom dimensions and heritability patterns. This study aimed to investigate the dimensional characteristics of PNS and their relationships with schizotypal features in first-degree relatives (FDRs).

MATERIALS AND METHODS

The study included 142 patients, 142 FDRs, and 71 healthy controls (HC). Patients were evaluated with the Positive and Negative Symptom Scale (PANSS), Brief Negative Symptom Scale (BNSS), Calgary Depression Scale for Schizophrenia (CDSS), and Simpson-Angus Scale (SAS). Schizotypy Personality Questionnaire was applied to FDR and HC groups. Clinical symptoms were compared between primary-PNS, secondary-PNS, and non-PNS groups. In addition, schizotypy scores were compared between FDRs and HCs. Then, the relationship between the symptoms of the patients in the PNS group and the schizotypy scores of their relatives was evaluated by multiple regression analysis.

RESULTS

All negative symptom dimension scores were similar in primary-PNS and secondary-PNS and lowest in non-PNS. PNS-FDR had higher in all schizotypy scores than non-PNS-FDR and HC, except for lack of close friends and social anxiety. In the PNS group, positive symptom severity and PANSS experiential deficit scores significantly predicted positive and negative schizotypy scores in relatives. Negative schizotypy was associated with asociality.

CONCLUSIONS

The PNS is likely a subtype in which the genetic basis of negative symptoms is stronger and is associated with genetic abnormalities shared by positive and negative schizotypy dimensions in relatives. Family-based genetic studies will be beneficial in enlightening the genetic etiology of PNS.

Caring for critically ill patients with a mental illness: A discursive paper providing an overview and case exploration of the delivery of intensive care to people with psychiatric comorbidity

AIM

To address the need for additional education in the management of mental illness in the critical care setting by providing a broad overview of the interrelationship between critical illness and mental illness. The paper also offers practical advice to support critical care staff in managing patients with mental illness in critical care by discussing two hypothetical case scenarios involving aggressive and disorganised behaviour. People living with mental illness are over-represented among critically unwell patients and experience worse outcomes, contributing to a life expectancy up to 30 years shorter than their peers. Strategic documents call for these inequitable outcomes to be addressed. Staff working in intensive care units (ICUs) possess advanced knowledge and specialist skills in managing critical illness but have reported limited confidence in managing patients with comorbid mental illness.

DESIGN & METHODS

A discursive paper, drawing on clinical experience and research of the authors and current literature.

RESULTS

Like all people, patients with mental illnesses draw on their cognitive, behavioural, social and spiritual resources to cope with their experiences during critical illness. However, they may have fewer resources available due to co-morbid mental illness, a history of trauma and social disadvantage. By identifying and sensitively addressing patients' underlying needs in a trauma-informed way, demonstrating respect and maximising patient autonomy, staff can reduce distress and disruptive behaviours and promote recovery. Caring for patients who are distressed and/or display challenging behaviours can evoke strong and unpleasant emotional responses. Self-care is fundamental to maintaining a compassionate approach and effective clinical judgement. Staff should be enabled to accept and acknowledge emotional responses and access support-informally with peers and/or through formal mechanisms as needed. Organisational leadership and endorsement of the principles of equitable care are critical to creation of the environment needed to improve outcomes for staff and patients.

RELEVANCE TO CLINICAL PRACTICE

ICU nurses hold an important role in the care of patients with critical illnesses and are ideally placed to empower, advocate for and comfort those patients also living with mental illness. To perform these tasks optimally and sustainably, health services have a responsibility to provide nursing staff with adequate education and training in the management of mental illnesses, and sufficient formal and informal support to maintain their own well-being while providing this care.

PATIENT AND PUBLIC INVOLVEMENT

This paper is grounded in accounts of patients with mental illness and clinicians providing care to patients with mental illness in critical care settings but there was no direct patient or public contribution.

Ulotaront: review of preliminary evidence for the efficacy and safety of a TAAR1 agonist in schizophrenia

Ulotaront is a trace amine-associated receptor 1 (TAAR1) agonist in Phase 3 clinical development for the treatment of schizophrenia. Ulotaront was discovered through a unique, target-agnostic approach optimized to identify drug candidates lacking D2 and 5-HT2A receptor antagonism, while demonstrating an antipsychotic-like phenotypic profile in vivo. The mechanism of action (MOA) of ulotaront is thought to be mediated by agonism at TAAR1 and serotonin 5-HT1A receptors. Ulotaront has completed two Phase 2 trials (4-week acute study and 26-week open-label extension) which led to Breakthrough Therapy Designation from the US Food and Drug Administration for the treatment of schizophrenia. In the double-blind, placebo-controlled, acute study, ulotaront was associated with significant (p < 0.001) improvement in Positive and Negative Syndrome Scale (PANSS) total score (effect size [ES]: 0.45), with improvements vs. placebo also observed across secondary endpoints. Post-hoc analyses of the acute trial revealed additional evidence to support the effect of ulotaront on negative symptoms. In the 4-week study, ulotaront was well-tolerated, with an incidence of adverse events (AEs) numerically lower compared to placebo (45.8% vs. 50.4%; with a number needed to harm [NNH] for individual ulotaront AEs all > 40). The open-label extension demonstrated further improvement across schizophrenia symptoms and confirmed the tolerability of ulotaront, with a 6-month completion rate of 67%. Based on current data, ulotaront shows potential to be a first-in-class TAAR1 agonist for the treatment of schizophrenia with a safety and efficacy profile distinct from current antipsychotics.

The motivation and pleasure deficits but not expressivity affects social functioning through cognitive function in male patients with schizophrenia: A structural equation model

OBJECTIVE

This study aims to compare cognitive function and social functioning in male schizophrenia patients with deficit syndrome (DS) and non-DS, and to explore the associations among two different dimensions of negative symptoms (motivation and pleasure (MAP) and expressivity (EXP) deficits), cognitive function and social functioning base on a Structural Equation Model (SEM).

METHODS

The current study enrolled 161 male schizophrenia patients and 120 age- and education- matched healthy controls. The DS and non-DS group were categorized by the Chinese version of Schedule for the Deficit Syndrome (SDS). The psychotic and negative symptoms were evaluated by the Brief Psychiatric Rating Scale (BPRS) and the Brief Negative Symptoms Scale (BNSS). The Social functioning was measured by Scale of Social function in Psychosis Inpatients (SSPI). A battery of classical neurocognitive tests was used for assessing cognition including sustained vigilance/attention, cognitive flexibility, ideation fluency and visuospatial memory.

RESULTS

Our study indicated that DS patients performed worser in cognitive function and social functioning than non-DS patients. The SEM model demonstrated that MAP significantly affected social functioning through direct influence and mediation of cognitive function. However, our results found that EXP had little influence on cognitive function and social function.

CONCLUSION

Our findings provided evidence supporting that DS may represent as a subtype of schizophrenia, and the MAP factor play a pivotal role to influence the cognitive and social functioning in schizophrenia patients.

Cariprazine for negative symptoms in early psychosis: a pilot study with a 6-month follow-up

Background

Cariprazine, a novel antipsychotic drug that is a partial agonist with preferential binding to the D3 receptor, has demonstrated efficacy in clinical trials across all symptom domains, including negative symptoms, which can occur early in the course of psychotic illness. However, evidence, to date regarding its effects in early psychosis patients with primary negative symptoms has been limited.

Objectives

To evaluate the efficacy of cariprazine for negative symptoms in early psychosis patients.

Methods

Demographic and clinical information of the study population were collected from the electronic records and PANSS scale administered at baseline, 3 and 6 months. Tolerability and discontinuation reasons, where applicable, were also recorded.

Results

Ten patients with early psychosis (four men and six women, mean age - 25.5  years) with prominent or predominant negative symptoms were treated with cariprazine (range 1.5 - 3 mg). Three patients discontinued cariprazine within the first 3  months due to patient choice, lack of response and non-compliance, respectively. In the remaining patients, there was a significant reduction in the mean negative PANSS score from baseline to 6 months (from 26.3 to 10.6), mean total PANSS score (from 81.4 to 43.3) and in the mean positive PANSS score (from 14.4 to 9.9) which correspond to a 53.1, 41.5, and 28.5% mean score reduction.

Conclusion

This pilot study suggests that cariprazine is a safe and effective treatment in early psychosis, particularly for the alleviation of negative symptoms which remains an area of unmet treatment need.

Negative Symptom Inventory-Self-Report (NSI-SR): Initial development and validation

Negative symptoms (i.e., anhedonia, avolition, asociality, blunted affect, alogia) are frequently observed in the schizophrenia-spectrum (SZ) and associated with functional disability. While semi-structured interviews of negative symptoms represent a gold-standard approach, they require specialized training and may be vulnerable to rater biases. Thus, brief self-report questionnaires measuring negative symptoms may be useful. Existing negative symptom questionnaires demonstrate that this approach may be promising in schizophrenia, but no measure has been devised for use across stages of psychotic illness. The present study reports initial psychometric validation of the Negative Symptom Inventory-Self-Report (NSI-SR), the self-report counterpart of the Negative Symptom Inventory-Psychosis Risk clinical interview. The NSI-SR is a novel transphasic negative symptoms measure assessing the domains of anhedonia, avolition, and asociality. The NSI-SR and related measures were administered to two samples: 1) undergraduates (n = 335), 2) community participants, including: SZ (n = 32), clinical-high risk for psychosis (CHR, n = 25), and healthy controls matched to SZ (n = 31) and CHR (n = 30). The psychometrically trimmed 11-item NSI-SR showed good internal consistency and a three-factor solution reflecting avolition, asociality, and anhedonia. The NSI-SR demonstrated convergent validity via moderate to large correlations with clinician-rated negative symptoms and related constructs in both samples. Discriminant validity was supported by lower correlations with positive symptoms in both samples; however, correlations with positive symptoms were still significant. These initial psychometric findings suggest that the NSI-SR is a reliable and valid brief questionnaire capable of measuring negative symptoms across phases of psychotic illness.

Postsurgical morbidity and mortality favorably informs deep brain stimulation for new indications including schizophrenia and schizoaffective disorder

Background

Deep brain stimulation (DBS) shows promise for new indications like treatment-refractory schizophrenia in early clinical trials. In the first DBS clinical trial for treatment refractory schizophrenia, despite promising results in treating psychosis, one of the eight subjects experienced both a symptomatic hemorrhage and an infection requiring device removal. Now, ethical concerns about higher surgical risk in schizophrenia/schizoaffective disorder (SZ/SAD) are impacting clinical trial progress. However, insufficient cases preclude conclusions regarding DBS risk in SZ/SAD. Therefore, we directly compare adverse surgical outcomes for all surgical procedures between SZ/SAD and Parkinson's disease (PD) cases to infer relative surgical risk relevant to gauging DBS risks in subjects with SZ/SAD.

Design

In the primary analysis, we used browser-based statistical analysis software, TriNetX Live (trinetx.com TriNetX LLC, Cambridge, MA), for Measures of Association using the Z-test. Postsurgical morbidity and mortality after matching for ethnicity, over 39 risk factors, and 19 CPT 1003143 coded surgical procedures from over 35,000 electronic medical records, over 19 years, from 48 United States health care organizations (HCOs) through the TriNetX Research Network™. TriNetXis a global, federated, web-based health research network providing access and statistical analysis of aggregate counts of deidentified EMR data. Diagnoses were based on ICD-10 codes. In the final analysis, logistic regression was used to determine relative frequencies of outcomes among 21 diagnostic groups/cohorts being treated with or considered for DBS and 3 control cohorts.

Results

Postsurgical mortality was 1.01-4.11% lower in SZ/SAD compared to the matched PD cohort at 1 month and 1 year after any surgery, while morbidity was 1.91-2.73% higher and associated with postsurgical noncompliance with medical treatment. Hemorrhages and infections were not increased. Across the 21 cohorts compared, PD and SZ/SAD were among eight cohorts with fewer surgeries, nine cohorts with higher postsurgical morbidity, and fifteen cohorts within the control-group range for 1-month postsurgical mortality.

Conclusions

Given that the subjects with SZ or SAD, along with most other diagnostic groups examined, had lower postsurgical mortality than PD subjects, it is reasonable to apply existing ethical and clinical guidelines to identify appropriate surgical candidates for inclusion of these patient populations in DBS clinical trials.

Effects of bilateral, bipolar-nonbalanced, frontal transcranial Direct Current Stimulation (tDCS) on negative symptoms and neurocognition in a sample of patients living with schizophrenia: Results of a randomized double-blind sham-controlled trial

Negative symptoms (NS), conceived as Avolition-Apathy (AA) and Expressive Deficit (EXP) domains, and neurocognitive impairments represent unmet therapeutic needs for patients with schizophrenia. The present study investigated if bilateral bipolar-nonbalanced frontal transcranial Direct Current Stimulation (tDCS) could improve these psychopathological dimensions. This randomized, double-blind, sham-controlled study (active-tDCS versus sham-tDCS, both, n = 25) included 50 outpatients diagnosed with schizophrenia clinically stabilized. Patients received 20-min 2 mA active-tDCS or sham-tDCS (anode: left Dorsolateral Prefrontal Cortex; cathode: right orbitofrontal region). Primary outcomes included: PANSS-Negative subscale, Negative Factor (Neg-PANSS), AA and EXP domains; neurocognitive performance at Brief Assessment of Cognition in Schizophrenia. Secondary outcomes included: PANSS subscales and total score, Disorganized/Concrete (DiscC-PANSS) and Positive Factors, Clinical Global Impression (CGI) scores, clinical insight at Scale to Assess Unawareness of Mental Disorder (SUMD). Analysis of covariance (ANCOVA) was performed evaluating between-group changes over time. Significant improvements following active-tDCS were observed for all NS measures (all, p < 0.001; d > 0.8) and for working memory (p = 0.025, d = 0.31). Greater variations following to active treatment emerged also for PANSS-General Psychopathology subscale (p < 0.001; d = 0.54), PANSS total score (p < 0.001; d = 0.69), CGI indexes (all, p < 0.001; d > 0.6), DiscC-PANSS (p < 0.001; d = 0.80) and SUMD-general Unawareness index (p = 0.005; d = 0.15) but not for positive symptoms and others insight measures. Good safety/tolerability profiles were found. Bilateral bipolar-nonbalanced frontal-tDCS is a non-pharmacological approach in schizophrenia effectively improving NS, particularly the AA and EXP domains, probably acting by modulating dysfunctional cortical-subcortical networks. Preliminary results also suggest working memory improvements following tDCS. Further studies are needed to confirm the neurobiological basis of these results.

Do different adverse childhood experiences lead to specific symptoms of psychosis in adulthood? A systematic review of the current literature

Previous research has demonstrated significant associations between adverse childhood experiences (ACEs) and risks of psychosis. Further research has examined underlying mechanisms to understand the relationship between these variables. This review aimed to explore the associations between various ACEs and the development of different psychotic symptoms in adulthood. The Cochrane Library, Cinahl, PsychINFO, Medline, Embase, and Web of Science were searched from January 1980 to November 2021 to ensure a systematic review of relevant literature. Poverty, fostering, adoption, childhood emotional and physical neglect, and childhood physical (CPA), sexual (CSA), and emotional abuse (CEA) significantly correlated with delusions. Significant relationships were found between hallucinations and CSA and CPA. Paranoia correlated with violent adversities including CPA, assault, and witnessing killing. Limited associations were identified for thought disorder and negative symptoms. The findings of this review indicate that there may be a degree of specificity between various ACEs and psychotic symptoms, but these findings are subject to some limitations. The findings also demonstrate the importance of inquiring about and addressing ACE in clinical practice to develop formulations and treatment plans for individuals with psychosis.

Medial temporal lobe and basal ganglia volume trajectories in persistent negative symptoms following a first episode of psychosis

BACKGROUND

Persistent negative symptoms (PNS, e.g., avolition, anhedonia, alogia) are present in up to 30% of individuals diagnosed with a first episode of psychosis and greatly impact functional outcomes. PNS and secondary PNS (sPNS: concomitant with positive, depressive, or extrapyramidal symptoms) may index distinct pathophysiologies reflected by structural brain changes, particularly in the medial temporal lobe (MTL) and basal ganglia.

AIMS

We sought to characterize dynamic brain changes related to PNS over the course of 2 years following a first episode of psychosis.

METHOD

Longitudinal volumetric trajectories within the MTL (hippocampus, parahippocampal gyrus, entorhinal cortex, perirhinal cortex) and basal ganglia (caudate, putamen, pallidum) were investigated in 98 patients with first-episode psychosis and 86 healthy controls using generalized estimating equations.

RESULTS

In left hippocampus, PNS (n = 25 at baseline) showed decreased volumes over time, sPNS (n = 26) volumes remained stable, and non-PNS (n = 47) volumes increased over time to control levels. PNS-specific changes were observed in left hippocampus and left perirhinal cortex, with the greatest decline from 12 to 24 months to levels significantly below those of non-PNS and controls. Affective/non-affective diagnosis, antipsychotic medication dosage and adherence at baseline did not significantly impact these findings. Basal ganglia volume trajectories did not distinguish between PNS and sPNS.

CONCLUSIONS

The current study highlights distinct structural brain trajectories in PNS that are prominent in the left MTL. Basal ganglia alterations may contribute to PNS irrespective of their etiology. Left MTL volume reductions were most evident after 1 year of treatment, highlighting the importance of targeted early interventions.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Corpus Callosum Volume in Patients with First-Episode Psychosis

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Meta-analysis of structural and functional brain abnormalities in schizophrenia with persistent negative symptoms using activation likelihood estimation

BACKGROUND

Persistent negative symptoms (PNS) include both primary and secondary negative symptoms that persist after adequate treatment, and represent an unmet therapeutic need. Published magnetic resonance imaging (MRI) evidence of structural and resting-state functional brain abnormalities in schizophrenia with PNS has been inconsistent. Thus, the purpose of this meta-analysis is to identify abnormalities in structural and functional brain regions in patients with PNS compared to healthy controls.

METHODS

We systematically searched PubMed, Web of Science, and Embase for structural and functional imaging studies based on five research methods, including voxel-based morphometry (VBM), diffusion tensor imaging (DTI), functional connectivity (FC), the amplitude of low-frequency fluctuation or fractional amplitude of low-frequency fluctuation (ALFF/fALFF), and regional homogeneity (ReHo). Afterward, we conducted a coordinate-based meta-analysis by using the activation likelihood estimation algorithm.

RESULTS

Twenty-five structural MRI studies and thirty-two functional MRI studies were included in the meta-analyses. Our analysis revealed the presence of structural alterations in patients with PNS in some brain regions including the bilateral insula, medial frontal gyrus, anterior cingulate gyrus, left amygdala, superior temporal gyrus, inferior frontal gyrus, cingulate gyrus and middle temporal gyrus, as well as functional differences in some brain regions including the bilateral precuneus, thalamus, left lentiform nucleus, posterior cingulate gyrus, medial frontal gyrus, and superior frontal gyrus.

CONCLUSION

Our study suggests that structural brain abnormalities are consistently located in the prefrontal, temporal, limbic and subcortical regions, and functional alterations are concentrated in the thalamo-cortical circuits and the default mode network (DMN). This study provides new insights for targeted treatment and intervention to delay further progression of negative symptoms.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42022338669].

Developments in Biological Mechanisms and Treatments for Negative Symptoms and Cognitive Dysfunction of Schizophrenia

The causal mechanisms and treatment for the negative symptoms and cognitive dysfunction in schizophrenia are the main issues attracting the attention of psychiatrists over the last decade. The first part of this review summarizes the pathogenesis of schizophrenia, especially the negative symptoms and cognitive dysfunction from the perspectives of genetics and epigenetics. The second part describes the novel medications and several advanced physical therapies (e.g., transcranial magnetic stimulation and transcranial direct current stimulation) for the negative symptoms and cognitive dysfunction that will optimize the therapeutic strategy for patients with schizophrenia in future.

Elucidating negative symptoms in the daily life of individuals in the early stages of psychosis

BACKGROUND

It remains poorly understood how negative symptoms are experienced in the daily lives of individuals in the early stages of psychosis. We aimed to investigate whether altered affective experience, anhedonia, social anhedonia, and asociality were more pronounced in individuals with an at-risk mental state for psychosis (ARMS) and individuals with first-episode psychosis (FEP) than in controls.

METHODS

We used the experience sampling methodology (ESM) to assess negative symptoms, as they occurred in the daily life of 51 individuals with FEP and 46 ARMS, compared with 53 controls.

RESULTS

Multilevel linear regression analyses showed no overall evidence for a blunting of affective experience. There was some evidence for anhedonia in FEP but not in ARMS, as shown by a smaller increase of positive affect (BΔat-risk v. FEP = 0.08, p = 0.006) as the pleasantness of activities increased. Against our expectations, no evidence was found for greater social anhedonia in any group. FEP were more often alone (57%) than ARMS (38%) and controls (35%) but appraisals of the social situation did not point to asociality.

CONCLUSIONS

Overall, altered affective experience, anhedonia, social anhedonia and asociality seem to play less of a role in the daily life of individuals in the early stages of psychosis than previously assumed. With the experience of affect and pleasure in daily life being largely intact, changing social situations and appraisals thereof should be further investigated to prevent development or deterioration of negative symptoms.

Mechanisms Underlying Motivational Dysfunction in Schizophrenia

Negative symptoms are a debilitating feature of schizophrenia which are often resistant to pharmacological intervention. The mechanisms underlying them remain poorly understood, and diagnostic methods rely on phenotyping through validated questionnaires. Deeper endo-phenotyping is likely to be necessary in order to improve current understanding. In the last decade, valuable behavioural insights have been gained through the use of effort-based decision making (EBDM) tasks. These have highlighted impairments in reward-related processing in schizophrenia, particularly associated with negative symptom severity. Neuroimaging investigations have related these changes to dysfunction within specific brain networks including the ventral striatum (VS) and frontal brain regions. Here, we review the behavioural and neural evidence associated with negative symptoms, shedding light on potential underlying mechanisms and future therapeutic possibilities. Findings in the literature suggest that schizophrenia is characterised by impaired reward based learning and action selection, despite preserved hedonic responses. Associations between amotivation and reward-processing deficits have not always been clear, and may be mediated by factors including cognitive dysfunction or dysfunctional or self-defeatist beliefs. Successful endo-phenotyping of negative symptoms as a function of objective behavioural and neural measurements is crucial in advancing our understanding of this complex syndrome. Additionally, transdiagnostic research–leveraging findings from other brain disorders, including neurological ones–can shed valuable light on the possible common origins of motivation disorders across diseases and has important implications for future treatment development.

Network Analysis of Symptom Comorbidity in Schizophrenia: Relationship to Illness Course and Brain White Matter Microstructure

INTRODUCTION

Recent network-based analyses suggest that schizophrenia symptoms are intricately connected and interdependent, such that central symptoms can activate adjacent symptoms and increase global symptom burden. Here, we sought to identify key clinical and neurobiological factors that relate to symptom organization in established schizophrenia.

METHODS

A symptom comorbidity network was mapped for a broad constellation of symptoms measured in 642 individuals with a schizophrenia-spectrum disorder. Centrality analyses were used to identify hub symptoms. The extent to which each patient's symptoms formed clusters in the comorbidity network was quantified with cluster analysis and used to predict (1) clinical features, including illness duration and psychosis (positive symptom) severity and (2) brain white matter microstructure, indexed by the fractional anisotropy (FA), in a subset (n = 296) of individuals with diffusion-weighted imaging (DWI) data.

RESULTS

Global functioning, substance use, and blunted affect were the most central symptoms within the symptom comorbidity network. Symptom profiles for some patients formed highly interconnected clusters, whereas other patients displayed unrelated and disconnected symptoms. Stronger clustering among an individual's symptoms was significantly associated with shorter illness duration (t = 2.7; P = .0074), greater psychosis severity (ie, positive symptoms expression) (t = -5.5; P < 0.0001) and lower fractional anisotropy in fibers traversing the cortico-cerebellar-thalamic-cortical circuit (r = .59, P < 0.05).

CONCLUSION

Symptom network structure varies over the course of schizophrenia: symptom interactions weaken with increasing illness duration and strengthen during periods of high positive symptom expression. Reduced white matter coherence relates to stronger symptom clustering, and thus, may underlie symptom cascades and global symptomatic burden in individuals with schizophrenia.

Validation of the lithuanian version of the self-evaluation of negative symptoms scale (SNS)

PURPOSE

To validate the Lithuanian version of the Self-Evaluation Negative Symptoms Scale (Lith-SNS).

MATERIALS AND METHODS

A double translation from French to Lithuanian and back was performed. We included patients from in-patient and out-patient settings that had a diagnosis of paranoid schizophrenia according to ICD-10 criteria and were screened as free from acute psychotic symptoms using the Mini International Neuropsychiatric Interview (MINI). Participants were evaluated using the Brief Psychiatric Rating Scale (BRPS) and completed the Lith-SNS scale. We measured internal consistency, convergent validity, and discriminant validity of Lith - SNS comparing its scores with BPRS negative and positive symptom subscores.

RESULTS

A total of 67 participants were evaluated. Cronbach's alpha (α) for all 20 items of Lith-SNS (α = 0.82), and for the five subscores (α = 0.76) showed good internal consistency. Factor analysis showed a 2-factor solution which accounted for 70.12% of the variance with the first factor accounting for 53.3% and the second factor accounting for 16.8% of the variance. Lith-SNS total scores and all five subscores significantly correlated with BPRS negative symptoms subscores showing good convergent validity. There was a correlation between the Positive subscore of BPRS and the alogia subscore of Lith-SNS (r = 0.39, p = 0.001), but no correlations with other subscores or the total Lith-SNS score showing adequate discriminant validity.

CONCLUSIONS

Lithuanian version of SNS is a valuable tool to evaluate negative symptoms of schizophrenia with good internal consistency, convergent, and discriminant validity.

Assessing olfactory, memory, social and circadian phenotypes associated with schizophrenia in a genetic model based on Rim

Schizophrenia shows high heritability and several of the genes associated with this disorder are involved in calcium (Ca2+) signalling and synaptic function. One of these is the Rab-3 interacting molecule-1 (RIM1), which has recently been associated with schizophrenia by Genome Wide Association Studies (GWAS). However, its contribution to the pathophysiology of this disorder remains unexplored. In this work, we use Drosophila mutants of the orthologue of RIM1, Rim, to model some aspects of the classical and non-classical symptoms of schizophrenia. Rim mutants showed several behavioural features relevant to schizophrenia including social distancing and altered olfactory processing. These defects were accompanied by reduced evoked Ca2+ influx and structural changes in the presynaptic terminals sent by the primary olfactory neurons to higher processing centres. In contrast, expression of Rim-RNAi in the mushroom bodies (MBs), the main memory centre in flies, spared learning and memory suggesting a differential role of Rim in different synapses. Circadian deficits have been reported in schizophrenia. We observed circadian locomotor activity deficits in Rim mutants, revealing a role of Rim in the pacemaker ventral lateral clock neurons (LNvs). These changes were accompanied by impaired day/night remodelling of dorsal terminal synapses from a subpopulation of LNvs and impaired day/night release of the circadian neuropeptide pigment dispersing factor (PDF) from these terminals. Lastly, treatment with the commonly used antipsychotic haloperidol rescued Rim locomotor deficits to wildtype. This work characterises the role of Rim in synaptic functions underlying behaviours disrupted in schizophrenia.

Neutrophils to lymphocytes ratio and psychosis in 22q11.2 deletion syndrome - Clinical and scientific implications

BACKGROUND

Individuals with 22q11.2 deletion syndrome (22q11.2DS) are at risk for having both psychotic and immune disorders, thus, implying a possible link between the two. The aim of the current study was to evaluate the usefulness of the neutrophiles to leukocytes ratio (NLR), an inflammatory marker, as a bio-marker for overt and prodromal psychotic symptoms in 22q11.2DS.

METHODS

Forty-nine individuals with 22q11.2DS (13 with psychotic disorders and 36 without psychotic disorders) and 30 age- and sex-matched healthy controls underwent psychiatric evaluation using a structured psychiatric interview, the Scale of Prodromal Symptoms (SOPS) and the Global Assessment of Functioning (GAF) scale. Blood samples were collected from all participants on the day of assessment. NLR was calculated, compared among the study groups and correlated with SOPS and GAF scores. The non-psychotic 22q11.2DS group was further divided into high- and low-inflammation groups by NLR values and the analyses were done again.

RESULTS

NLR was higher in the psychotic- and the high-inflammation non-psychotic 22q11.2DS groups compared to the low-inflammation non-psychotic 22q11.2DS group and controls. In the high-inflammation non-psychotic 22q11.2DS group NLR increase was associated with an increase of total negative symptoms scores on SOPS and a decrease in GAF scores.

CONCLUSION

Our results suggest the potential utility of NLR as a bio-marker for psychotic disorders and subthreshold prodromal symptoms in 22q11.2DS. Furthermore, they imply that a disequilibrium between the innate and adaptive arms of the immune system facilitates the progression of psychosis in at risk populations. Further longitudinal studies are warranted to validate our findings, as this was a cross sectional observation.

EPA guidance on assessment of negative symptoms in schizophrenia

Background

During the last decades, a renewed interest for negative symptoms (NS) was brought about by the increased awareness that they interfere severely with real-life functioning, particularly when they are primary and persistent.

Methods

In this guidance paper, we provide a systematic review of the evidence and elaborate several recommendations for the conceptualization and assessment of NS in clinical trials and practice.

Results

Expert consensus and systematic reviews have provided guidance for the optimal assessment of primary and persistent negative symptoms; second-generation rating scales, which provide a better assessment of the experiential domains, are available; however, NS are still poorly assessed both in research and clinical settings.

This European Psychiatric Association (EPA) guidance recommends the use of persistent negative symptoms (PNS) construct in the context of clinical trials and highlights the need for further efforts to make the definition of PNS consistent across studies in order to exclude as much as possible secondary negative symptoms. We also encourage clinicians to use second-generation scales, at least to complement first-generation ones.

The EPA guidance further recommends the evidence-based exclusion of several items included in first-generation scales from any NS summary or factor score to improve NS measurement in research and clinical settings. Self-rated instruments are suggested to further complement observer-rated scales in NS assessment.

Several recommendations are provided for the identification of secondary negative symptoms in clinical settings.

Conclusions

The dissemination of this guidance paper may promote the development of national guidelines on negative symptom assessment and ultimately improve the care of people with schizophrenia.

Adult Attachment and Personal, Social, and Symptomatic Recovery From Psychosis: Systematic Review and Meta-Analysis

Despite growing evidence for the role of attachment in psychosis, no quantitative review has yet been published on the relationship in this population between insecure attachment and recovery in a broad sense. We therefore used meta-analytic techniques to systematically appraise studies on the relationship between attachment and symptomatic, social and personal recovery in clients with a psychotic disorder. Using the keywords attachment, psychosis, recovery and related terms, we searched six databases: Embase, Medline Epub (OVID), Psycinfo (OVID), Cochrane Central (trials), Web of Science, and Google Scholar. This yielded 28 studies assessing the associations between adult attachment and recovery outcome in populations with a psychotic disorder. The findings indicated that insecure anxious and avoidant attachment are both associated with less symptomatic recovery (positive and general symptoms), and worse social and personal recovery outcomes in individuals diagnosed with a psychotic disorder. The associations were stronger for social and personal recovery than for symptomatic recovery. Attachment style is a clinically relevant construct in relation to the development and course of psychosis and recovery from it. Greater attention to the relationship between attachment and the broad scope of recovery (symptomatic, social, and personal) will improve our understanding of the illness and efficacy of treatment for this population.

Humor in Psychiatry: Lessons From Neuroscience, Psychopathology, and Treatment Research

Humor is a ubiquitous human characteristic that is socially motivated at its core and has a broad range of significant positive effects on emotional well-being and interpersonal relationships. Simultaneously, however, impairments in humor abilities have often been described in close association with the occurrence and course of neuropsychiatric disorders, such as schizophrenia, social anxiety, or depression. In the past decade, research in the neuroimaging and psychiatric domain has substantially progressed to (i) characterize impaired humor as an element of psychopathology, and (ii) shed light on the neurobiological mechanisms underlying the role of humor in neuropsychiatric diseases. However, (iii) targeted interventions using concepts of positive psychology have revealed first evidence that a systematic training and/or a potential reactivation of humor-related skills can improve rehabilitative outcome in neuropsychiatric patient groups. Here, we sought to integrate evidence from neuroscience, as well as from psychopathology and treatment research to shed more light on the role of humor in psychiatry. Based on these considerations, we provide directions for future research and application in mental health services, focusing on the question of how our scientific understanding of humor can provide the basis for psychological interventions that foster positive attitudes and well-being.

Case Report: Severe Side Effects Following Treatment With First Generation Antipsychotics While Cariprazine Leads to Full Recovery

Schizophrenia is a psychiatric disorder characterized by positive, negative, cognitive and affective symptoms. Patient cooperation with health care professionals, compliance with the treatment regime, and regular use of medications are some of the preconditions that need to be met for a favorable disease course. A negative experience following the use of a first-generation antipsychotic to treat first-episode psychosis can negatively affect a patient's motivation for further medication use. In the clinical case reported here, cariprazine was able to restore one such patient's confidence in therapy and facilitated their cooperation with the physician, thereby ensuring effective control of negative and positive symptoms and good functioning for a period of 1 year. Cariprazine may be a good option for maintenance therapy following first-episode psychosis, especially in situations in which a patient has had a negative first experience associated with antipsychotic medication use.

Nurses' Assessment of Sedation of Patients With Mental Illness: Scale Development and Validation

The current study aimed to determine the reliability and validity of a tool for evaluating the sedation of patients with mental illness. A literature review and focus group interviews were used to develop the initial questionnaire. The scale was tested on a sample of 412 representative patients and analyzed using exploratory factor analysis, concurrent validity, and internal consistency. The final scale comprised 14 items across four factors related to sedation of patients with mental illness: arousal, affect, cognitive status, and physical performance. The scale has high sensitivity and specificity and can discriminate among levels of sedation for patients with mental illness. [Journal of Psychosocial Nursing and Mental Health Services, 58(12), 22-31.].

Is that schizophrenia or frontotemporal dementia? Supporting clinicians in making the right diagnosis

Schizophrenia (SCH) and frontotemporal dementia (FTD) are neurobehavioral syndromes characterized by a profound alteration in personal and social conduct. Differential diagnosis between SCH and FTD remains a challenge. In this short narrative review, we summarize evidences regarding similarities and differences between these disorders to support clinicians in making the right diagnosis. Reports of FTD misdiagnosed as schizophrenia or schizophrenia-like psychosis are frequently reported in the literature. The behavioural variant of FTD (bvFTD) along with familial FTD characterized by delusions and hallucinations represent the medical conditions that best illustrate overlaps between psychiatry and neurology. Neuropsychological patterns of core deficits and anatomical and physiological brain alterations primarily concur in differencing such disorders while additional research on genetic alterations and their reflection on clinical phenotypes should be implemented in the near future. In some cases, a correct diagnosis should be made within an interdisciplinary clinical setting by complementary competences and follow-up visits to evaluate pathology evolution.

Frontal white matter abnormalities reveal the pathological basis underlying negative symptoms in antipsychotic-naïve, first-episode patients with adolescent-onset schizophrenia: Evidence from multimodal brain imaging

A major challenge in schizophrenia is to uncover the pathophysiological basis of its negative symptoms. Recent neuroimaging studies revealed that disrupted structural properties of frontal white matter (FWM) are associated with the negative symptoms of schizophrenia. However, there is little direct functional evidence of FWM for negative symptoms in schizophrenia. To address this issue, we combined resting-state connectome-wide functional connectivity (FC) and diffusion tensor imaging tractography to investigate the alteration of FWM underlying the negative symptoms in 39 drug-naive patients with adolescent-onset schizophrenia (AOS) and 31 age- and sex- matched healthy controls (HCs). Results revealed that the intrinsic FC and structural properties (fraction anisotropy and fibers) of the left FWM correspond to individual negative symptoms in AOS. Moreover, the serotonin network (raphe nuclei, anterior and posterior cingulate cortices, and prefrontal and inferior parietal cortices) and FWM-cingulum network were found to contributed to the negative symptom severity in AOS. Furthermore, the patients showed abnormal functional and structural connectivities between the interhemispheric FWM compared with HCs. Importantly, the decreased fiber counts between the interhemispheric FWM were inversely correlated with the negative symptoms in AOS. Our findings demonstrated the association between FWM and negative symptoms, and offered initial evidence by using WM connectome to uncover WM functional information in schizophrenia.

A systematic review and narrative synthesis of data-driven studies in schizophrenia symptoms and cognitive deficits

To tackle the phenotypic heterogeneity of schizophrenia, data-driven methods are often applied to identify subtypes of its symptoms and cognitive deficits. However, a systematic review on this topic is lacking. The objective of this review was to summarize the evidence obtained from longitudinal and cross-sectional data-driven studies in positive and negative symptoms and cognitive deficits in patients with schizophrenia spectrum disorders, their unaffected siblings and healthy controls or individuals from general population. Additionally, we aimed to highlight methodological gaps across studies and point out future directions to optimize the translatability of evidence from data-driven studies. A systematic review was performed through searching PsycINFO, PubMed, PsycTESTS, PsycARTICLES, SCOPUS, EMBASE and Web of Science electronic databases. Both longitudinal and cross-sectional studies published from 2008 to 2019, which reported at least two statistically derived clusters or trajectories were included. Two reviewers independently screened and extracted the data. In this review, 53 studies (19 longitudinal and 34 cross-sectional) that conducted among 17,822 patients, 8729 unaffected siblings and 5520 controls or general population were included. Most longitudinal studies found four trajectories that characterized by stability, progressive deterioration, relapsing and progressive amelioration of symptoms and cognitive function. Cross-sectional studies commonly identified three clusters with low, intermediate (mixed) and high psychotic symptoms and cognitive profiles. Moreover, identified subgroups were predicted by numerous genetic, sociodemographic and clinical factors. Our findings indicate that schizophrenia symptoms and cognitive deficits are heterogeneous, although methodological limitations across studies are observed. Identified clusters and trajectories along with their predictors may be used to base the implementation of personalized treatment and develop a risk prediction model for high-risk individuals with prodromal symptoms.

Aerobic exercise and cognitive functioning in schizophrenia: Results of a 1-year follow-up from a randomized controlled trial

We previously reported that adding combined, individual, and group aerobic exercise (AE) interventions to the treatment as usual (TAU) for schizophrenia showed significant improvements in cognition and other outcomes compared to those with TAU alone in a randomized controlled trial. Following the promising results of our previous study, this 1-year follow-up study evaluated the improvements in cognition and other outcomes with TAU + AE compared to those with TAU alone. Of 41 randomized patients, 40 were included in the intent-to-treat population-20 in the TAU + AE and 20 in the TAU alone; all patients completed the 1-year follow-up. Mixed models were applied to assess changes in outcome measures over time from baseline to 1-year follow-up. At 1-year follow-up, the TAU + AE demonstrated significant group by time interaction effects in several cognitive domains, intrinsic motivation, negative symptom, interpersonal relations, and functional outcome compared with the TAU alone. Our results demonstrate that the improvements in cognition and other outcomes with TAU + AE were maintained and that functional outcome improved over 1-year follow-up. These findings show that the improvements sustained for each outcome over 1 year have the potential to offer opportunities for greater transitions to improvement of functional outcome.

Negative Symptoms in Schizophrenia: A Review and Clinical Guide for Recognition, Assessment, and Treatment

Schizophrenia is frequently a chronic and disabling disorder, characterized by heterogeneous positive and negative symptom constellations. The objective of this review was to provide information that may be useful for clinicians treating patients with negative symptoms of schizophrenia. Negative symptoms are a core component of schizophrenia that account for a large part of the long-term disability and poor functional outcomes in patients with the disorder. The term negative symptoms describes a lessening or absence of normal behaviors and functions related to motivation and interest, or verbal/emotional expression. The negative symptom domain consists of five key constructs: blunted affect, alogia (reduction in quantity of words spoken), avolition (reduced goal-directed activity due to decreased motivation), asociality, and anhedonia (reduced experience of pleasure). Negative symptoms are common in schizophrenia; up to 60% of patients may have prominent clinically relevant negative symptoms that require treatment. Negative symptoms can occur at any point in the course of illness, although they are reported as the most common first symptom of schizophrenia. Negative symptoms can be primary symptoms, which are intrinsic to the underlying pathophysiology of schizophrenia, or secondary symptoms that are related to psychiatric or medical comorbidities, adverse effects of treatment, or environmental factors. While secondary negative symptoms can improve as a consequence of treatment to improve symptoms in other domains (ie, positive symptoms, depressive symptoms or extrapyramidal symptoms), primary negative symptoms generally do not respond well to currently available antipsychotic treatment with dopamine D₂ antagonists or partial D₂ agonists. Since some patients may lack insight about the presence of negative symptoms, these are generally not the reason that patients seek clinical care, and clinicians should be especially vigilant for their presence. Negative symptoms clearly constitute an unmet medical need in schizophrenia, and new and effective treatments are urgently needed.

Does metabolic status affect serum levels of BDNF and MMP-9 in patients with schizophrenia?

The purpose of the article: Brain-derived neurotrophic factor (BDNF) and matrix metalloproteinase-9 (MMP-9) are involved in the processes of neurogenesis, synaptic plasticity, learning and memory. Growing number of studies shows a relationship between BDNF or MMP-9 and schizophrenia. Also, BDNF and MMP-9 levels may be affected by metabolic parameters, such as obesity or dyslipidemia. Our hypothesis is that alterations of BDNF or MMP-9 levels in schizophrenia might be secondary to metabolic abnormalities, often found among schizophrenia patients. Materials and methods: We have compared BDNF and MMP-9 between patients with schizophrenia (n = 64, age 49 ± 8.2 y) and healthy controls (n = 32, age 51 ± 8.9 y) in the context of cardio-metabolic parameters. Serum levels of BDNF and MMP-9 were measured using ELISA test, body composition parameters were determined using bioelectric impedance analysis. Results and conclusions: Our results showed significantly lowered serum BDNF concentration in the schizophrenia group (schizophrenia: 23.8 ± 7.83 ng/mL, control: 27.69 ± 8.11 ng/mL, p = 0.03). Serum MMP-9 concentration in schizophrenia group did not differ compared with the control group (schizophrenia: 456.8 ± 278.4 ng/mL, control: 341.5 ± 162.4 ng/mL, p = 0.07). After adjusting for age, all anthropometric parameters, body composition and laboratory tests BDNF were still significantly lower in the schizophrenia group. However, MMP-9 became significantly elevated in the schizophrenia group after adjusting for several anthropometric and body composition covariates. Our results confirmed reduced serum BDNF concentration in patients with schizophrenia. Also, this reduction seems to be independent of metabolic abnormalities. On the other hand, our hypothesis that MMP-9 level in schizophrenia is altered due to metabolic abnormalities might be true.

The effect of mind-body and aerobic exercise on negative symptoms in schizophrenia: A meta-analysis

OBJECTIVE

This meta-analysis aims to evaluate the effects of different types of physical exercise (PE) on negative symptoms in schizophrenia patients. Mind-body exercise (MBE), aerobic exercise (AE) and resistance training (RT) will be investigated.

METHOD

The Cochrane Library, Medline, Embase and PsycINFO were searched from their inception until April 26, 2018. Randomized controlled trials comparing PE with any control group in patients with schizophrenia were included when negative symptoms had been assessed. This meta-analysis was conducted according to the PRISMA guidelines. The methodological quality of the included studies was assessed with the Cochrane Risk of Bias assessment tool. Moderator, sensitivity, and meta regression analyses were conducted to explore causes of heterogeneity and impact of study quality.

RESULTS

We included 22 studies (N = 1249). The overall methodological quality was poor. The meta-analysis (random effects model) showed a medium significant effect in favor of any PE intervention (Hedges' g = 0.434, 95% CI = 0.196-0.671) versus any control condition. MBE and AE respectively showed a medium significant effect (Hedges' g = 0.461) and a small significant effect (Hedges' g = 0.341) versus any control condition. The effect of RT could not be examined. The overall heterogeneity was high (I² = 76%) and could not be reduced with moderator or sensitivity analyses.

CONCLUSION

This meta-analysis demonstrated that PE could be a promising intervention in the treatment of negative symptoms. However, the quality of the included studies was low and heterogeneity was high, which makes it impossible to make a clear recommendation. Therefore, results should be interpreted with care.

Social Values and Determinants of Cultural Fit in Quebec: The Roles of Ancestry, Linguistic Group, and Mental Health Status

Many quantitative cross-cultural research studies assume that cultural groups consist of anyone born and raised in the same country. Applying these criteria to the formation of study samples may produce cohorts that share a country but are heterogeneous in relevant domains of culture. For example, in Canada, Franco- and Anglo-Canadians are generally assumed to represent different linguistic groups but the same cultural group. However, speaking a different first language also can mean exposure to different media, information, and conventions, which are known to shape certain cultural domains, such as social values. Other factors may also produce cultural heterogeneity. For example, ancestral origins and recency of familial migration may influence endorsed social values after exposure to diverse cultures or norms. Mental health status or psychiatric conditions may also influence subscription of social values due to different lifestyle demands. Understanding the nuanced contributions of diverse backgrounds to cultural membership and fit (i.e., the degree to which an individual behaves like other cultural members) is useful when performing quantitative cross-cultural studies to minimize alternative explanations for statistical outcomes. This study used Cultural Consensus Analysis (CCA) to assess the cultural fit of social values for 222 Canadians, who had participated in cross-cultural neuropsychological experiments. CCA is an anthropological statistical method for evaluating cultural agreement of a sample. Participants were systematically evaluated by linguistic groups (French and English), migratory generation (1st-3rd+), and mental health status (healthy and patient). Group and individual variances were statistically interrogated. Results demonstrated that Franco- and Anglo-Canadians represent different cultural groups cohabitating in Quebec. Social values dividing Franco- and Anglo-Canadians were also identified. Second and third generation Canadians held more heterogeneous social values than Canadians, whose families had migrated earlier. Second generation Canadians with psychiatric disorders showed notably reduced cultural fit with other Canadians, which supports other literature reporting difficulties experienced by second generation migrants. However, third and later generations of Canadians with psychiatric disorders held a greater range of social values compared to healthy Canadians but still were good fits for Canadian culture. This study concluded that linguistic group and migratory generation partially determines cultural group for the social values domain while mental health status does not, contrary to theories proposed by previous literature.

Impaired introspective accuracy in schizophrenia: an independent predictor of functional outcomes

INTRODUCTION

Individuals with schizophrenia present across a spectrum of symptomatology. Disability remains a debilitating reality across varying disease presentations and remains pervasive despite psychiatric medications. Cognition (neuro/social cognition) and negative symptoms have emerged as the strongest predictors of real-world disability, but account for <50% of the variance in outcomes.

METHODS

Our attempts to determine what accounts for the remaining 50% of variance has shown that poor introspective accuracy (IA) may be the most potent predictor of functional outcomes 25% of individuals with schizophrenia. We define IA as the adequacy of self-assessments of ability, skills, performance, or decisions. We suggest that IA is a progression of metacognition and can extend beyond cognition to include misestimation of prior and likely future performance in social or other adaptively relevant situations.

RESULTS

Additionally, IA is bidirectional and self-orientated. Emerging research has found that IA of neurocognitive ability better predicts everyday functional deficits than scores on performance-based measures or neurocognitive skills and has found that IA of social cognition accounts unique variance in real-world disability above social cognitive performance.

DISCUSSION

We argue that impaired IA, affecting 25-50% of patients with schizophrenia, in the absence or minimal presence of other impairments might be the most powerful predictor of functional outcomes.

Health related quality of life in patients having schizophrenia negative symptoms - a systematic review

Background: Schizophrenia negative symptoms (SNS) contribute substantially to poor functional outcomes, loss in productivity and poor quality of life. It is unclear which instruments may be used for assessing quality of life in patients with SNS. Objective: The objective of this review was to identify instruments assessing health-related quality of life (HRQoL) validated in patients with SNS and to assess their level of validation. Data sources: We conducted a systematic literature review in Medline and the ISPOR database in March 2016 to identify studies on the quality of life in patients with SNS published by March 2016. Data extraction: Psychometric properties and validation steps. Data synthesis: After applying inclusion/exclusion criteria, 49 studies were selected for the analysis of HRQoL instruments; however, none of these instruments only addressed patients with SNS. Of these, 19 HRQoL instruments used in patients with schizophrenia or including patients with SNS among others, in the context of instrument validation, were identified (4 generic, 10 non-specific mental health, 5 schizophrenia-specific). Conclusion: No HRQoL instrument has been validated in patients with SNS only; for the remaining instruments identified, it remains unclear whether they were intended to capture HRQoL in patients with SNS.