Treatments of Negative Symptoms in Schizophrenia: Meta-Analysis of 168 Randomized Placebo-Controlled Trials

Effect of probiotics on C-reactive protein levels in schizophrenia: Evidence from a systematic review and meta-analysis

BACKGROUND

Inflammatory markers play a pivotal role in schizophrenia, as they provide insight into the neuroinflammatory processes occurring in the context of the disorder. Elevated levels of these markers, particularly C-reactive protein (CRP), can indicate an underlying immune system dysregulation, potentially influencing symptom severity and progression. Recognizing these markers has led to investigate the use of probiotics as an adjuvant to improve the treatment of schizophrenia. The main objective of this study is to rigorously evaluate the efficacy of probiotics in reducing plasma levels of CRP in patients with schizophrenia.

METHODS

A systematic search and meta-analysis were conducted to review randomized clinical trials following the PRISMA methodology. The following search strategy ((SCHIZO* OR PSYCHOTIC OR PSYCHOSES) AND (PROBIOTIC* OR BIFIDOBACTER* OR LACTOBACILL*)) was used for searching publications between June-December 2024 on the PubMed, Web of Science, and APA PsycINFO databases. Individual study quality was assessed with the Cochrane risk of bias (RoB2) and the certainty of total evidence was assessed with the GRADE system.

RESULTS

The primary outcome assessed was the impact of probiotic supplementation on plasma CRP levels. Out of 78 studies initially identified, 4 were finally included in the meta-analysis. Three out four studies found a significant reduction in high-sensitivity C-reactive protein levels in the supplemented compared with the placebo group. The pooled analysis revealed a significant reduction in CRP levels with probiotic supplementation, with a standardized mean difference (SMD) of -0.46, (95 % CI -0.719; -0.201; p = 0.001).

CONCLUSIONS

The synthesis and meta-analysis of available literature provide evidence for the potential role of probiotics in the reduction of serum CRP in schizophrenia compared with placebo. However, more clinical trials with better control of experimental design are needed before a clear recommendation as adjuvant therapy can be made.

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.

Inflammation is associated with avolition and reduced resting state functional connectivity in corticostriatal reward circuitry in patients with schizophrenia

Low-grade inflammation has been associated with negative symptoms in patients with schizophrenia. Of these symptoms, deficits in motivation and pleasure, especially in the domain of avolition, are particularly disabling. Effects of inflammation on motivational deficits in patients with depression are associated with disruptions in corticostriatal reward circuitry involving the inferior ventral striatum (iVS) and ventromedial prefrontal cortex (vmPFC). Accordingly, we examined the relationships among inflammation, negative symptoms, and corticostriatal reward circuitry in patients with schizophrenia. Negative symptoms and high sensitivity C-reactive protein (hsCRP) were obtained in 57 individuals with schizophrenia. Resting state functional connectivity (rsFC) was obtained from a subset of 43 of these individuals. Associations were tested between hsCRP and the motivation and pleasure (MAP) and expressivity (EXP) dimensions of the Brief Negative Symptom Scale (BNSS) as well as targeted rsFC between iVS and vmPFC. Covariates in all statistical models included age, sex, race, smoking, body mass index, depression, and chlorpromazine equivalents. hsCRP was significantly associated with BNSS MAP (β = 0.34, pcorr = 0.022, specifically the domains of avolition and asociality (p < 0.05), but not BNSS EXP (β = -0.17, pcorr = 0.57) or the domains of blunted affect or alogia (both p > 0.05). hsCRP was also significantly associated with decreased rsFC from right iVS to vmPFC (β=-0.37, pcorr = 0.029), which in turn, was associated with increased avolition in individuals with higher (hsCRP >2 mg/L) but not lower inflammation (β=-14.01, p = 0.007 vs. β = 0.07, p = 0.77, respectively). hsCRP was associated with reduced avolition and corticostriatal rsFC in patients with schizophrenia and increased inflammation, underscoring the need for further research to replicate these associations with brain connectivity changes in this subgroup of individuals with schizophrenia.

Resource deprivation in the home environment is associated with negative symptoms in outpatients with Schizophrenia

Limited negative symptoms treatment effectiveness may result from environmental resource deprivation that is a barrier for performing goal-directed, recreational, and social activities. This study showed that environmental resource deprivation in the home environment was greater for people with schizophrenia (n = 39) than 32 demographically-matched healthy controls (CN). Greater environmental resource reductions for performing goal-directed, recreational, and social activities were associated with greater negative symptoms, even after controlling for income and secondary negative symptom factors (depression, positive symptoms).

A Phase 3, Randomized, Double-Blind, Placebo-Controlled Study to Evaluate the Efficacy and Safety of Pimavanserin as an Adjunctive Treatment for the Negative Symptoms of Schizophrenia (ADVANCE-2) in Patients With Predominant Negative Symptoms

BACKGROUND AND HYPOTHESES

Negative symptoms of schizophrenia (NSS) carry a substantial burden, and there are no treatments currently approved for NSS. The efficacy of pimavanserin, a selective 5-HT2A inverse agonist and antagonist, in treating NSS was assessed.

STUDY DESIGN

ADVANCE-2 was a phase 3, randomized, double-blind, placebo-controlled study of pimavanserin in patients with schizophrenia and predominantly negative symptoms. Patients were randomized (1:1) to receive pimavanserin (34 mg/day) or placebo alongside ongoing background antipsychotic medication. Eligible adults were aged 18-55 years and had access to a caregiver. The primary and key secondary endpoints were the change from baseline to week 26 in the Negative Symptom Assessment-16 (NSA-16) total score and Clinical Global Impression-Schizophrenia Scale-Severity (CGI-SCH-S) negative symptom score, respectively.

STUDY RESULTS

Of the 454 randomized patients, 71 (39 placebo; 32 pimavanserin) discontinued and 383 (188 placebo; 195 pimavanserin) completed the study. The safety and full analysis sets comprised 453 and 446 patients, respectively. The NSA-16 change from baseline to week 26 was not significantly different between groups (least squares mean difference: -0.67; SE, 0.95; [95% CI: -2.54, 1.20]; P = .48; Cohen's d effect size: 0.07). Treatment-emergent adverse events occurred in 30.4% with pimavanserin and 40.3% with placebo.

CONCLUSIONS

In this study, pimavanserin was well tolerated, and although it demonstrated a similar treatment effect as in the prior phase 2 study favoring pimavanserin, treatment with pimavanserin vs placebo did not result in significant differences for primary or other endpoints.

Exploratory analysis of the relationship between striatal connectivity and apathy during phosphodiesterase 10 inhibition in schizophrenia: findings from a randomized crossover trial

BACKGROUND

Negative symptoms in schizophrenia remain a challenge with limited therapeutic strategies. The novel compound RG7203 promotes reward learning via dopamine D1-dependent signaling and therefore holds promise, especially to improve the apathy dimension of negative symptoms. When tested as add-on to antipsychotic medication, apathy did not change significantly with RG7203 versus placebo. However, the response varied across patients, and a subset showed clinically relevant improvement of apathy. It remains unclear if these interindividual differences are related to neurobiological correlates.

METHODS

Due to the predominant binding of RG7203 in the striatum, we investigated how apathy changes with RG7203 are related to changes in cortico-striatal connectivity by computing rank correlations (rs). In a post hoc exploratory analysis, we focused on cortico-striatal circuits that have been associated with apathy and previously showed connectivity alterations in schizophrenia. In a double-blind, 3-way randomized and counterbalanced crossover study, resting-state functional magnetic resonance imaging was acquired from 24 individuals with schizophrenia following a 3-week administration of placebo, 5 mg, or 15 mg of RG7203 as an add-on to antipsychotics.

RESULTS

We found that 5 mg or 15 mg of RG7203 did not lead to significant changes in striatal connectivity. However, changes in the apathy response across individuals were reflected by striatal connectivity changes. Apathy improvement with 5 mg and 15 mg RG7203 vs. placebo was associated with increased striatal connectivity to paracingulate (rs = - 0.58, p = 0.047 for both doses) and anterior cingulate regions (rs = - 0.56, p = 0.047 for both doses). Such associations were not observed for the negative symptom dimension of expressive deficits. We additionally observed that lower striatal connectivity to paracingulate and anterior cingulate regions during placebo was linked to greater apathy improvement during RG7203 treatment at both doses (rs = 0.61-0.79 and p = 0.0002-0.02 across regions and doses).

CONCLUSIONS

These findings suggest that striatal connectivity with the paracingulate gyrus and anterior cingulate cortex may be associated with apathy modulation under RG7203 treatment. Replication and further elaboration of these findings in larger clinical studies could help to advance biologically informed and personalized treatment options for negative symptoms.

TRIAL REGISTRATION

NCT02824055, registered on ClinicalTrials.gov (2016-06-21).

Socially relevant affective learning in psychosis: Relations to deficits in motivation and pleasure and cognitive ability

Negative symptoms are common in psychotic disorders and significantly contribute to functional impairment. Deficits in reward processing and memory have been implicated as important factors which contribute to negative symptoms, leading to speculation that deficits in learning and memory of socially relevant information may be particularly important. Previous work has also found poorer learning of positive social behavior associations in psychotic disorders, but limitations have prevented an examination of symptom correlates of this diminished learning. In the present study, we used an updated social affective learning task to examine whether diminished accuracy in learning the affective value of others was related to motivation and pleasure negative symptoms as well as cognitive deficits. Results indicated that participants were able to use both positive and negative behavioral information to generate accurate socially evaluative perceptions. Results also demonstrated that reduced accuracy of learning from positive behavioral information was related to greater motivation and pleasure symptoms and cognitive deficits, including working memory, while reduced accuracy of learning from negative behavioral information was only related to cognitive deficits across multiple domains. When controlling for cognition, motivation and pleasure symptoms were no longer related to positive affective learning, but working memory remained related to learning when controlling for motivation and pleasure symptoms. These findings underscore the role of diminished positive affective learning in negative symptoms and suggest that poorer learning of the positive value of others may be one pathway through which cognitive deficits lead to reduced reward anticipation, defeatist performance beliefs, and negative symptoms.

Negative Symptoms in Schizophrenia: An Update on Research Assessment and the Current and Upcoming Treatment Landscape

The negative symptoms of schizophrenia include diminished emotional expression, avolition, alogia, anhedonia, and asociality, and due to their low responsiveness to available treatments, are a primary driver of functional disability in schizophrenia. This narrative review has the aim of providing a comprehensive overview of the current research developments in the treatment of negative symptoms in schizophrenia, and begins by introducing the concepts of primary, secondary, prominent, predominant, and broadly defined negative symptoms. We then compare and contrast commonly used research assessment scales for negative symptoms and review the evidence for the specific utility of widely available off-label and investigational treatments that have been studied for negative symptoms. Mechanism of action/putative treatments included are antipsychotics (D2R antagonists), N-methyl-D-aspartate receptor (NMDAR) and other glutamatergic modulators, serotonin receptor (5-HTR) modulators, anti-inflammatory agents, antidepressants, pro-dopaminergic modulators (non-D2R antagonists), acetylcholine modulators, oxytocin, and phosphodiesterase (PDE) inhibitors. With the caveat that no compounds are definitively proven as gold-standard treatments for broadly defined negative symptoms, the evidence base supports several potentially beneficial off-label and investigational medications for treating negative symptoms in schizophrenia, such as monotherapy with cariprazine, olanzapine, clozapine, and amisulpride, or adjunctive use of memantine, setrons such as ondansetron, minocycline, and antidepressants. These medications are widely available worldwide, generally tolerable and could be considered for an off-label, time-limited trial for a predesignated period of time, after which a decision to switch or stay can be made based on clinical response. Among investigational medications, NMDAR agonists, muscarinic agonists, and LB-102 remain under study. Suggestions for future research include reducing placebo effects by designing studies with a smaller number of high-quality study sites, potentially increasing the use of more precise rating scales for negative symptoms, and focused studies in people with predominant negative symptoms.

Neurobiological fingerprints of negative symptoms in schizophrenia identified by connectome-based modeling

AIM

As a central component of schizophrenia psychopathology, negative symptoms result in detrimental effects on long-term functional prognosis. However, the neurobiological mechanism underlying negative symptoms remains poorly understood, which limits the development of novel treatment interventions. This study aimed to identify the specific neural fingerprints of negative symptoms in schizophrenia.

METHODS

Based on resting-state functional connectivity data obtained in a large sample (n = 132) of first-episode drug-naïve schizophrenia patients (DN-FES), connectome-based predictive modeling (CPM) with cross-validation was applied to identify functional networks that predict the severity of negative symptoms. The generalizability of identified networks was then validated in an independent sample of n = 40 DN-FES.

RESULTS

A connectivity pattern significantly driving the prediction of negative symptoms (ρ = 0.28, MSE = 81.04, P = 0.012) was identified within and between networks implicated in motivation (medial frontal, subcortical, sensorimotor), cognition (default mode, frontoparietal, medial frontal) and error processing (medial frontal and cerebellum). The identified networks also predicted negative symptoms in the independent validation sample (ρ = 0.37, P = 0.018). Importantly, the predictive model was symptom-specific and robust considering the potential effects of demographic characteristics and validation strategies.

CONCLUSIONS

Our study discovers and validates a comprehensive network model as the unique neural substrates of negative symptoms in schizophrenia, which provides a novel and comprehensive perspective to the development of target treatment strategies for negative symptoms.

Capturing changes in social functioning and positive affect using ecological momentary assessment during a 12-month trial of xanomeline and trospium chloride in schizophrenia

BACKGROUND

Experiential negative symptoms (NS) are determinants of disability in schizophrenia (SCZ). Xanomeline/Trospium Chloride (X/T), an M1/M4 muscarinic receptor agonist, is an approved monotherapy for treatment of schizophrenia, including NS. We used remote ecological momentary assessments (EMA) to track changes in indicators of NS during 12 months of outpatient treatment with X/T.

METHODS

After discontinuing previous medications, 566 outpatients with SCZ received open-label X/T monotherapy for up to 12 months. Participants completed 3 EMA surveys 7 days a week, one week a month. Surveys queried whether participants were home vs. away and alone vs with someone, as well as productive and unproductive activities, and moods. Hierarchical linear modeling (HLM) examined temporal changes and the relationships between the indicators of NS.

RESULTS

500 participants answered one or more EMA surveys and 350 met 33 % adherence criteria, answering a total of 40,464 surveys, with overall adherence among these participants at 66 %. During treatment with X/T, there were significant decreases in surveys at home (p < .001), alone (p < .001), and engaging in unproductive activities (p < .001). There were significant increases in productive activities both home (p < .001) and away (p < .001) and in positive affect (PA) (p < .001). Improvements in PA converged with reduced unproductive activities, particularly when others were present (p < .001).

CONCLUSIONS

Behavioral indicators of NS improved early and were sustained with X/T treatment. Improvements were multidimensional, shifting toward more time with others, away from home, and engaged in productive activities. These improvements were associated with increases in PA, consistent with previous EMA studies of NS.

Overview of Novel Antipsychotic Drugs: State of the Art, New Mechanisms, and Clinical Aspects of Promising Compounds

Antipsychotic medications are a vast class of drugs used for the treatment of psychotic disorders such as schizophrenia. Although numerous compounds have been developed since their introduction in the 1950s, several patients do not adequately respond to current treatments, or they develop adverse reactions that cause treatment discontinuation. Moreover, in the past few decades, discoveries in the pathophysiology of psychotic disorders have opened the way for experimenting with novel compounds that have alternative mechanisms of action, with some of them showing promising results in early trials. The scope of this review was to summarize the novel antipsychotics developed, their current experimental status, and their mechanisms of action. In particular, we analyzed the main classes of investigational antipsychotics, such as monoamine, glutamate, acetylcholine, cannabinoid receptor modulators, enzyme inhibitors, ion channel modulators, and mixed receptor modulators. In addition, the safety profiles and adverse effects of these drugs were carefully evaluated, considering the relevance of these aspects for patients' drug adherence and quality of life, especially in the long-term treatment. Lastly, we tried to understand which compounds have greater potential to be approved by the principal drug regulatory agencies in the next years and if they could be used for diseases other than psychotic disorders.

Subcortical and insula functional connectivity aberrations and clinical implications in first-episode schizophrenia

INTRODUCTION

Schizophrenia is a complex mental disorder whose pathophysiology remains elusive, particularly in the roles of subcortex. This study aims to explore the role of subcortex and insula and their relationship with symptom changes in first-episode schizophrenia (FES) patients by utilizing machine learning algorithms and functional connectivity (FC).

METHODS

The study encompasses 261 participants, sourced from two independent samples of FES patients and their matched healthy controls (HC). The discovery dataset includes 77 FES patients at baseline (FES0W) and 77 matched HCs, with the patients undergoing a follow-up scan after eight weeks of antipsychotic treatment (FES8W, N = 34). A validation dataset from another region comprises 47 FES patients and 47 matched HCs.

RESULTS

Significant differences in subcortical FCs were observed between FES and controls, correlating with symptom severity and symptom changes. Machine learning models were developed to diagnose schizophrenia on an individual basis, achieving a balanced accuracy of 79.55 % across diverse centers.

CONCLUSIONS

These findings suggest that subcortical connectivity patterns offer potential as biomarkers for schizophrenia, enabling personalized treatment strategies and improving prognosis by facilitating early diagnosis.

Interaction between serum inflammatory cytokines and brain-derived neurotrophic factor in cognitive function among first-episode schizophrenia patients

BACKGROUND

The pathogenesis of cognitive impairment in schizophrenia (SCZ) remains unclear. Accumulating studies showed that inflammatory-immune dysregulation and altered brain derived neurotrophic factor (BDNF) levels play a crucial role in the psychopathology of SCZ. However, their association with cognitive dysfunction in first-episode SCZ patients has not been thoroughly investigated.

AIM

To explore the interaction effects between cognitive function and inflammatory cytokines and BDNF in first-episode SCZ.

METHODS

The current study is a cross-sectional case-control investigation that recruited 84 patients with first-episode SCZ (SCZ group) and 80 healthy controls (HCs group) at the Huzhou Third Municipal Hospital between August 2021 and September 2023. ELISA was employed to measure the serum levels of interleukin (IL)-1β, IL-4, IL-6, IL-10, and BDNF. The Chinese brief cognitive test (C-BCT) and the positive and negative syndrome scales were measured the severity of cognitive impairment and psychiatric symptoms.

RESULTS

Compared to the HC group, the SCZ group exhibited elevated IL-1β and IL-6 levels, decreased BDNF levels, and reduced C-BCT scores (all P < 0.001). In SCZ, BDNF was negatively correlated with IL-6 (r = -0.324, P < 0.05). Information processing speed was negatively correlated with IL-6 (r = -0.315, P < 0.05) and positively with BDNF (r = 0.290, P < 0.05); attention, working memory, comprehensive ability, and executive function were negatively correlated with IL-1β and IL-6 (all P < 0.05) and positively with BDNF (all P < 0.05). Multiple regression analysis showed IL-6 influenced C-BCT dimensions (β = -0.218 to -0.327, all P < 0.05); attention and executive ability were influenced by IL-1β (β = -0.199 to -0.261, all P < 0.05); comprehensive executive ability was influenced by BDNF (β = 0.209, P < 0.05).

CONCLUSION

Our findings suggested that interrelationships between immune dysfunction and neurotrophic deficiency might underlie the pathological mechanisms of cognitive impairments in first-episode SCZ patients.

Crocus sativus (saffron) adjunct to risperidone for negative symptoms of schizophrenia: a randomized, double-blind, placebo-controlled trial

Current treatments for schizophrenia encounter resistance, limited efficacy, and limiting complications, necessitating novel approaches. The effects of saffron on negative symptoms were investigated as it has shown neuroprotective and antipsychotic properties. Fifty-six clinically stable chronic schizophrenic outpatients were equally assigned to saffron 15 mg q12hr or placebo groups while continuing risperidone. The Positive and Negative Syndrome Scale (PANSS) was used to assess schizophrenia-related symptoms in weeks 4 and 8. Also, the patients were assessed for the Hamilton depression rating scale (HDRS) and adverse effects. The baseline characteristics of the groups were comparable (Ps > 0.05). There were significant time-treatment interaction effects on negative ( = 0.137), general psychopathology ( = 0.193), and total ( = 0.113) PANSS scores. Affirmatively, their reductions were significantly greater in the saffron group until weeks 4 (Cohen's ds = 0.922, 0.898, and 0.759, respectively) and 8 (Cohen's ds = 0.850, 1.047, and 0.705, respectively). Regarding the negative symptoms, a better 25% response rate was obtained in the saffron group until the endpoint (P = 0.003). The HDRS scores, extrapyramidal symptom rating scale scores, and side effect frequencies were comparable between the groups (Ps > 0.05). Saffron was beneficial for primary negative symptoms of chronic schizophrenia in a safe and tolerable manner. It also outperformed placebo in improving general psychopathology and total symptoms.

The Negative Symptom Inventory-Psychosis Risk (NSI-PR): Psychometric Validation of the Final 11-Item Version

BACKGROUND AND HYPOTHESES

The lack of psychometrically validated assessment tools designed specifically to assess negative symptoms in individuals at clinical high risk (CHR) for psychosis represents a significant barrier to the early identification and prevention of psychosis. To address this need, the Negative Symptom Inventory-Psychosis Risk (NSI-PR) was developed based on the iterative, data-driven approach recommended by the National Institute of Mental Health consensus conference on negative symptoms.

STUDY DESIGN

This manuscript reports the results of the second study phase that psychometrically validates the final 11-item version of the scale in data collected across 3 sites. A total of 222 participants (144 CHR and 78 clinical help-seeking controls) completed the NSI-PR, 1 week of ecological momentary assessment (EMA), and additional convergent and discriminant validity measures.

STUDY RESULTS

Structural analyses replicated the previously reported strong fit for the 5-factor (anhedonia, avolition, asociality, alogia, and blunted affect) and hierarchical structures (2 super-ordinate dimensions and 5 lower-level domains). The 5 domains and 2 dimensions generally demonstrated good internal consistency, temporal stability, and interrater reliability. Convergent validity was demonstrated in relation to the 16-item beta version of the NSI-PR, Structured Interview for Psychosis-risk Syndromes negative subscale, Global Functioning Scale social and role, and EMA measures. Discriminant validity was supported by low correlations with positive, disorganized, and general psychiatric symptoms.

CONCLUSIONS

Findings indicate the final 11-item version of the NSI-PR has sound psychometric properties. The scale, which is designed specifically for CHR individuals, is brief and appropriate for use in research and clinical contexts. Accompanying training materials have been developed to support its use in multisite trials.

Social network reductions are associated with negative symptoms in schizophrenia

BACKGROUND

A recent environmental systems theory of negative symptoms in schizophrenia (SZ) proposes a role for reductions in social networks that exist within microsystems (i.e., the contexts in which social interactions occur). However, it is unclear which aspects of social networks are most impacted in SZ and whether these are differentially associated with specific domains of negative symptoms. The current study aimed to address these gaps in the literature using a novel social network tool in combination with Ecological Momentary Assessment (EMA) and clinical ratings of negative symptoms.

METHODS

Participants included 40 outpatients diagnosed with SZ and 35 demographically matched healthy controls (CN) who completed the sociogram, Brief Negative Symptom Scale (BNSS), and 7 days of EMA surveys assessing anhedonia, avolition, and asociality. ANOVAs examined group differences in social network characteristics. Correlations examined associations between social network characteristics and negative symptoms measured via the BNSS and EMA.

RESULTS

Results indicated that: (1) SZ had greater social network reductions than CN, including lower: network density, number of microsystems, people in microsystems, connections across and within microsystems (p's < 0.05, d-value range 0.58 to 0.74); (2) these social network reductions were associated with greater severity of negative symptoms on the BNSS (r range - 0.28-0.34, p < .05) and asociality measured via EMA surveys (r's = - 0.24 to - 0.26, p's < 0.05).

CONCLUSIONS

Findings clarified the nature of social network dysfunction in SZ and identify novel targets for psychosocial interventions focused on modifying the number of social microsystems and the connections within/across these microsystems.

Long-term quality of life and social disconnection 20 years after a first episode psychosis, results from the 20-year follow-up of the OPUS trial

OBJECTIVE

Schizophrenia disorders severely impact social and occupational function and reduce quality of life, furthermore patients often suffer from social withdrawal and isolation. The aim of this study was to investigate long-term quality of life and social disconnection and determine 10-year changes in quality of life and social disconnection later in life in association with changes in symptom severity, cognition, and global function.

METHODS

We used assessments of quality of life and assessor rated social disconnection from the 10- and 20-year follow-up of the OPUS trial to examined 10-year changes in self-rated quality of life and social disconnection in the later stage of illness following a first episode psychosis. Self-rated social disconnection was only assessed in the 174 participants of the 20-year follow-up.

RESULTS

Twenty years after a first episode psychosis only half of the participants reported having face-to-face contact with someone in their network more than once a week, while 90 % reported often or always being able to get emotional support when needed. Quality of life ratings were lower in our study population compared to the general population. On average physical and environmental quality of life worsened from the 10- to the 20-year follow-up while psychological and social quality of life remained stable. All quality-of-life domains were associated with negative symptoms (physical QoL: b = -6.6, p < 0.001, psychological QoL: b = -8, p < 0.001, social QoL: b = -5.7, p < 0.001 and environmental QoL: b = -6.5, p < 0.001) and global function (physical QoL: b = -0. 47, p < 0.001, psychological QoL: b = 0.52, p < 0.001, social QoL: b = 0.31, p < 0.001 and environmental QoL: b = 0.49, p < 0.001).

CONCLUSION

Social disconnection seems to persist over time. Social disconnection and quality of life were associated with negative symptoms and poor functioning, therefore interventions aimed at improving global and social function might likely also improve quality of life.

The efficacy of Lactobacillus and Bifidobacterium in patients with schizophrenia: a meta-analysis

The modulation of gut microbiota through probiotics holds promise as a novel avenue for schizophrenia treatment. This study aims to analyze probiotic complementary therapy on individuals with schizophrenia systematically, to investigate probiotic efficacy, potential mechanisms, and implications for clinical practice. Adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched in Medline, Web of Science, Embase, ClinicalTrials.gov, CNKI, VIP, and WanFang databases using keywords ("probiotics" OR "prebiotics" OR "synbiotics" OR "Lactobacillus" OR "Bifidobacterium") AND ("schizophrenia"), focused on randomized controlled trials published before July 1, 2023. Among the identified studies, 8 randomized controlled trials met the inclusion criteria, encompassing a total of 342 participants in the intervention group and 306 participants in the control group. Our analysis revealed a statistically significant reduction (p = 0.03) in the total Positive and Negative Syndrome Scale (PANSS) scores following probiotic treatment in individuals with schizophrenia. While no statistical significance was observed in individual subscales (P > 0.05), significant improvements were noted in insulin levels, Insulin Resistance Index (IRI), and glucose levels. Additionally, the Quantitative Insulin Sensitivity Check Index (QUICKI) demonstrated a significant increase (all P < 0.05). The probiotic intervention significantly reduced gastrointestinal discomfort among schizophrenia patients (P = 0.003). This study suggests that probiotics could hold therapeutic potential for addressing clinical symptoms, abnormal glucose metabolism, and gastrointestinal discomfort in individuals with schizophrenia. Future research should encompass comparative trials employing robust experimental designs to explore the differential effects of various probiotic strains on schizophrenia treatment to provide evidence-based therapeutic approaches. TRIAL REGISTRATION: This review protocol was pre-registered on PROSPERO (No. CRD42023455273).

Mitochondrial dysfunction in psychiatric disorders

Psychiatric disorders are a heterogeneous group of mental disorders with abnormal mental or behavioral patterns, which severely distress or disable affected individuals and can have a grave socioeconomic burden. Growing evidence indicates that mitochondrial function plays an important role in developing psychiatric disorders. This review discusses the neuropsychiatric consequences of mitochondrial abnormalities in both animal models and patients. We also discuss recent studies associated with compromised mitochondrial function in various psychiatric disorders, such as schizophrenia (SCZ), major depressive disorder (MD), and bipolar disorders (BD). These studies employ various approaches including postmortem studies, imaging studies, genetic studies, and induced pluripotent stem cells (iPSCs) studies. We also summarize the evidence from animal models and clinical trials to support mitochondrial function as a potential therapeutic target to treat various psychiatric disorders. This review will contribute to furthering our understanding of the metabolic etiology of various psychiatric disorders, and help guide the development of optimal therapies.

Efficacy of Horticultural Therapy on Positive, Negative, and Affective Symptoms in Individuals with Schizophrenia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Objectives: Positive symptoms, negative symptoms, and emotional disturbances are core features of schizophrenia. Although horticultural therapy (HT) has shown promise as an adjunctive treatment, evidence supporting its effectiveness remains limited. This systematic review and meta-analysis aimed to assess the impact of HT on total symptoms, positive symptoms, negative symptoms, and emotional disturbances in individuals with schizophrenia. Methods: We conducted a search for randomized controlled trials (RCTs) published up to March 2024 across multiple databases, including PubMed, Embase, Cochrane Library, CINAHL, CEPS, CNKI, Wanfang, and Yiigle. A random-effects model was employed to calculate the standardized mean difference (SMD). Results: A total of 35 studies enrolling 2899 participants were included. Our results indicated that, in the short term (≦3 months), HT has moderate to large effect sizes on total symptoms (SMD = 0.690, 95% CI 0.463 to 0.916), positive symptoms (SMD = 0.695, 95% CI 0.038 to 1.351), negative symptoms (SMD = 0.681, 95% CI 0.395 to 0.967), depression (SMD = 0.646, 95% CI 0.334 to 0.959), and anxiety (SMD = 0.627, 95% CI 0.364 to 0.890), with more pronounced benefits for anxiety symptoms in patients with a shorter duration of illness. In the long term (>3 months), HT shows large effect sizes for total symptoms (SMD = 1.393, 95% CI 0.858 to 1.928), negative symptoms (SMD = 1.389, 95% CI 0.935 to 1.842), anxiety (SMD = 1.541, 95% CI 1.042 to 2.040), and moderate to large effect sizes for positive symptoms (SMD = 0.667, 95% CI 0.077 to 1.258) and depression (SMD = 0.707, 95% CI 0.198 to 1.217). Additionally, longer weekly treatment durations are associated with better outcomes for total symptoms and negative symptoms. Schizophrenia patients with more severe initial symptoms may be potential responders to HT. Conclusions: These findings support the efficacy of HT in improving symptoms and emotional well-being in schizophrenia patients. Further trials with more rigorous designs are warranted to confirm these benefits.

A generalisability theory approach to quantifying changes in psychopathology among ultra-high-risk individuals for psychosis

Distinguishing stable and fluctuating psychopathological features in young individuals at Ultra High Risk (UHR) for psychosis is challenging, but critical for building robust, accurate, early clinical detection and prevention capabilities. Over a 24-month period, 159 UHR individuals were assessed using the Positive and Negative Symptom Scale (PANSS). Generalisability Theory was used to validate the PANSS with this population and to investigate stable and fluctuating features, by estimating the reliability and generalisability of three factor (Positive, Negative, and General) and five factor (Positive, Negative, Cognitive, Depression, and Hostility) symptom models. Acceptable reliability and generalisability of scores across occasions and sample population were demonstrated by the total PANSS scale (Gr = 0.85). Fluctuating symptoms (delusions, hallucinatory behaviour, lack of spontaneity, flow in conversation, emotional withdrawal, and somatic concern) showed high variability over time, with 50-68% of the variance explained by individual transient states. In contrast, more stable symptoms included excitement, poor rapport, anxiety, guilt feeling, uncooperativeness, and poor impulse control. The 3-factor model of PANSS and its subscales showed robust reliability and generalisability of their assessment scores across the UHR population and evaluation periods (G = 0.77-0.93), offering a suitable means to assess psychosis risk. Certain subscales within the 5-factor PANSS model showed comparatively lower reliability and generalisability (G = 0.33-0.66). The identified and investigated fluctuating symptoms in UHR individuals are more amendable by means of intervention, which could have significant implications for preventing and addressing psychosis. Prioritising the treatment of fluctuating symptoms could enhance intervention efficacy, offering a sharper focus in clinical trials. At the same time, using more reliable total scale and 3 subscales can contribute to more accurate assessment of enduring psychosis patterns in clinical and experimental settings.

Global reward processing deficits predict negative symptoms transdiagnostically and transphasically in a severe mental illness-spectrum sample

Reward processing impairments are a key factor associated with negative symptoms in those with severe mental illnesses. However, past findings are inconsistent regarding which reward processing components are impaired and most strongly linked to negative symptoms. The current study examined the hypothesis that these mixed findings may be the result of multiple reward processing pathways (i.e., equifinality) to negative symptoms that cut across diagnostic boundaries and phases of illness. Participants included healthy controls (n = 100) who served as a reference sample and a severe mental illness-spectrum sample (n = 92) that included psychotic-like experiences, clinical high-risk for psychosis, bipolar disorder, and schizophrenia participants. All participants completed tasks measuring four RDoC Positive Valence System constructs: value representation, reinforcement learning, effort-cost computation, and hedonic reactivity. A k-means cluster analysis of the severe mental illness-spectrum samples identified three clusters with differential reward processing profiles that were characterized by: (1) global reward processing deficits (22.8%), (2) selective impairments in hedonic reactivity alone (40.2%), and (3) preserved reward processing (37%). Elevated negative symptoms were only observed in the global reward processing cluster. All clusters contained participants from each clinical group, and the distribution of these groups did not significantly differ among the clusters. Findings identified one pathway contributing to negative symptoms that was transdiagnostic and transphasic. Future work further characterizing divergent pathways to negative symptoms may help to improve symptom trajectories and personalized treatments.

Network intervention analysis indicates that roluperidone achieves its effect on negative symptoms of schizophrenia by targeting avolition

Roluperidone, a 5-HT2A, sigma2, and ɑ1A-adrenergic receptor antagonist, has proven efficacious for treating negative symptoms of schizophrenia in phase 2b and phase 3 clinical trials. Using network analysis, we demonstrated that the improvements observed in the phase 2b trial resulted from targeting avolition which was highly central and spurred a cascading effect of global negative symptom reductions when successfully treated. The current study aims to replicate these network findings using the phase 3 roluperidone clinical trial data. Participants included 496 schizophrenia patients with moderate to severe negative symptoms who were randomized to either roluperidone 32 mg/day (n =167), 64 mg/day (n = 162), or placebo (n = 167). Negative symptoms were assessed at baseline and weeks 2,4,8, and 12. Network intervention analysis (NIA) evaluated treatment-induced symptom changes over time to identify direct and indirect treatment effects. This analytic approach extends prior work by determining whether the symptoms with highest centrality have causal effects on the entire negative symptom construct and directly lead to symptom improvement. NIA indicated that the efficacious 64 mg/day dose of roluperidone had a direct effect on avolition, suggesting that changes in avolition propels treatment effects across the entire negative symptom constellation. These phase 3 findings replicated the phase 2b findings, indicating that from a network perspective, roluperidone achieves its effect by influencing the extent to which avolition drives other negative symptoms. These findings are relevant for understanding negative symptoms and how to treat them in neuropsychiatric disorders.

tDCS for the treatment of negative symptoms in youth at clinical-high-risk for psychosis: A feasibility study

Negative symptoms are often found in youth at clinical high risk (CHR) for psychosis. The present study explored the feasibility of using tDCS in conjunction with CBT in the treatment of negative symptoms in 5 youths at CHR. We sought to determine whether the protocol was feasible given the requirement for repeated visits over a three-week period, and to determine if measures of neurobiological change could be included, both acutely and following three weeks of stimulation. The results from this study suggest that the protocol is feasible for these youth, and the inclusion of MRI scanning sessions yielded good quality data.

Irregularity of visual motion perception and negative symptoms in schizophrenia

Schizophrenia (SZ) is a severe psychiatric disorder characterized by perceptual, emotional, and behavioral abnormalities, with cognitive impairment being a prominent feature of the disorder. Recent studies demonstrate irregularity in SZ with increased variability on the neural level. Is there also irregularity on the psychophysics level like in visual perception? Here, we introduce a methodology to analyze the irregularity in a trial-by-trial way to compare the SZ and healthy control (HC) subjects. In addition, we use an unsupervised clustering algorithm K-means + + to identify SZ subgroups in the sample, followed by validation of the subgroups based on intraindividual visual perception variability and clinical symptomatology. The K-means + + method divided SZ patients into two subgroups by measuring durations across trials in the motion discrimination task, i.e., high, and low irregularity of SZ patients (HSZ, LSZ). We found that HSZ and LSZ subgroups are associated with more negative and positive symptoms respectively. Applying a mediation model in the HSZ subgroup, the enhanced irregularity mediates the relationship between visual perception and negative symptoms. Together, we demonstrate increased irregularity in visual perception of a HSZ subgroup, including its association with negative symptoms. This may serve as a promising marker for identifying and distinguishing SZ subgroups.

Pharmacological Treatments of Negative Symptoms in Schizophrenia-An Update

Schizophrenia is a chronic psychotic disorder comprising positive symptoms, negative symptoms, and cognitive deficits. Negative symptoms are associated with stigma, worse functional outcomes, and a significant deterioration in quality of life. Clinical diagnosis is challenging despite its significance, and current treatments offer little improvement in the burden of negative symptoms. This article reviews current pharmacological strategies for treating negative symptoms. Dopaminergic, glutamatergic, serotonergic, noradrenergic, cholinergic, anti-inflammatory compounds, hormones, and psychostimulants are explored. Finally, we review pharmacological global treatment guidelines for negative symptoms. In general, switching to a second-generation antipsychotic seems to be most often recommended for patients with schizophrenia on first-generation antipsychotics, and an add-on antidepressant is considered when depression is also present. However, the treatment of negative symptoms remains an unmet need. Future, larger clinical studies and meta-analyses are needed to establish effective pharmacological agents for the effective treatment of negative symptoms.

Feuerstein Instrumental Enrichment Program for People With Schizophrenia After the First Episode of Psychosis: Protocol for an Open-Label Intervention Study

BACKGROUND

Schizophrenia is a disorder associated with neurocognitive deficits that adversely affect daily functioning and impose an economic burden. Cognitive rehabilitation interventions, particularly during the early phases of illness, have been shown to improve cognition, functionality, and quality of life. The Feuerstein Instrumental Enrichment (FIE) program, based on the Mediated Learning Experience and the Structural Cognitive Modifiability theory, has been applied in various disorders, but its applicability in schizophrenia has not yet been clarified.

OBJECTIVE

This study aims to investigate the effects of the FIE program on the functionality of patients with first-episode schizophrenia.

METHODS

In total, 17 patients will be recruited for an open-label intervention consisting of twice-weekly sessions for 10 weeks. The primary outcome measure will be changes in the Goal Achievement Scale score. Maze task performance from the Measurement and Treatment Research to Improve Cognition in Schizophrenia (MATRICS) battery will serve as a secondary outcome measure. At the same time, changes in Positive and Negative Syndrome Scale scores and other MATRICS domains will be analyzed as exploratory outcomes. Assessments will be administered before and after the intervention, with a follow-up period of 6 months.

RESULTS

This trial was preregistered in The Brazilian Registry of Clinical Trials (RBR-4gzhy4s). By February 2024, 11 participants were enrolled in the training. Recruitment is expected to be completed by May 2024. Data analysis will be conducted between May and September 2024. The results are expected to be published in January 2025.

CONCLUSIONS

This study may establish a protocol for the FIE program that uses mediation techniques for individuals in the early stages of schizophrenia. The results will add to the knowledge about strategies to promote cognitive skills and functional impairment in daily life.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/57031.

How does loneliness interact with positive, negative and depressive symptoms of psychosis? New insights from a longitudinal therapy process study

Cross-sectional research suggests an association between loneliness and psychotic symptoms, but the causal direction of this association is still unclear. Even though loneliness has been proposed as a potential treatment target to improve psychotherapy for psychosis, not much is known about its role in the treatment process. In this study, we re-analyzed data from a therapy process study to investigate the temporal dynamics between loneliness and psychotic symptoms throughout therapy and to explore whether state-of-the-art CBT for psychosis (CBTp) decreases loneliness. Over the course of up to 45 weekly sessions of CBTp, 57 patients reported their feelings of loneliness and current positive, negative and depressive symptom levels at each session. Multilevel regression revealed a reduction in all symptoms over time, but no reduction in loneliness. Time-lagged multilevel regression showed that loneliness predicted subsequent negative and depressive symptoms, whereas positive symptom levels predicted subsequent loneliness. Thus, changes in loneliness seem to be both cause and consequence of psychotic symptom changes. These findings highlight the importance of loneliness as a treatment target, particularly in patients with negative symptoms and depression. Future research should address loneliness-specific interventions as an augmentation of state-of-the-art CBTp.

Prevalence of prominent and predominant negative symptoms across different criteria for negative symptom severity and minimal positive symptoms: A comparison of different criteria

Negative symptoms are a source of disability in schizophrenia, but criteria for identifying patients for clinical trials are in flux. Minimum severity for negative symptoms is paired with a definition of minimal psychosis to identify predominant negative symptoms. Two previous successful negative symptoms treatment studies used very different severity and selection criteria. We compared the prevalence of participants meeting those two criteria in a large outpatient sample of participants with schizophrenia. Data from 867 outpatients with schizophrenia who participated in one of four NIMH-funded studies were analyzed. Common data elements included diagnoses, the PANSS, and an assessment of everyday functioning. We compared previous criterion for premoninant negative symptoms based on low levels of agitation and psychosis and different cut-offs for negative symptoms severity. 57 % of the participants met the agitation-based criteria for low scores and 33 % met the psychosis-based criteria. 18 % met total PANSS score ≥ 20 and 8 % met ≥24 prominent negative symptoms criteria. 14 % met low agitation and PANSS≥20 and 2 % met the low psychosis and negative symptoms ≥24 criteria. Participants who met all predominant criteria had more impairments in social functioning (all p < .001, all d > 0.37). Criteria for predominant negative symptoms from previous clinical trials identify widely different numbers of cases, with criteria for negative symptom severity and low symptoms both impacting. All criteria yield the expected profile of relatively specific social deficits. Even in unselected populations who participated in complex research protocols, 14 % meet low- agitation based criteria for predominant negative symptoms and many more participants would be expected to meet criteria with enrichment for the presence of negative symptoms.

The effects of mindful exercise on cognition in patients with schizophrenia: A systematic review and meta-analysis of randomized controlled trials

Cognitive impairment is a core symptom of schizophrenia. This study investigated the effects of mindful exercise on the cognitive performance of individuals with schizophrenia. A systematic review and meta-analysis were performed from inception to March 2023. The quality of included studies was evaluated using the Physiotherapy Evidence Database (PEDro) scale. A random effects model was used to generate the pooled effect size. Ten randomized controlled trials met the inclusion criteria with fair-to-good methodological quality. The results showed that Mindful exercise significantly improved global cognition in patients with schizophrenia (g = 0.25, p = .002). There was a significant difference in mindful exercise compared with the passive control group (g = 0.34, p = .002), whereas no significant difference was found between the mindful exercise and exercise intervention group (g = 0.09, p = .371). These findings indicate that mindful exercise could be promising for improving cognition in patients with schizophrenia.

The Impact of Childhood Trauma on the Negative Symptoms of Schizophrenia

ABSTRACT

Schizophrenia is a debilitating mental health disorder that imposes profound economic, societal, and personal burdens. The negative symptoms of schizophrenia ( i.e. , blunted affect, alogia, anhedonia, asociality, and avolition) are highly prevalent and pervasive in the psychotic disorder and pose significant resistance to available treatment options. Traumatic childhood experiences are strongly linked with the risk of developing schizophrenia. Most prior studies have primarily focused on positive symptoms of schizophrenia ( e.g. , hallucinations and delusions), whereas less attention has been given to negative symptoms. The current study investigated the relationship between childhood trauma ( i.e. , physical abuse, sexual abuse, and emotional abuse and neglect) and negative symptoms in a sample of schizophrenia outpatients and healthy controls ( n = 159 participants, including 99 patients with schizophrenia). The observations from the current study revealed that schizophrenia patients experienced a significantly greater degree of childhood trauma and negative symptoms than the control individuals. The results of the current study also indicated that more severe experiences of total childhood trauma ( i.e. , summation of all trauma types), physical abuse, and emotional neglect may increase the risk of schizophrenia patients reporting negative symptoms. However, childhood sexual and emotional abuse was found to have no impact on the degree of negative symptoms experienced by schizophrenia patients. Implications and limitations of the current study are discussed. In conclusion, we found that the severity of overall childhood trauma, physical abuse, and emotional neglect may play an important role in increasing the likelihood of schizophrenia patients reporting negative symptoms.

Disentangling negative and positive symptoms in schizophrenia and autism spectrum disorder

Autism spectrum disorder (ASD) and schizophrenia (SZ) share traits, especially in social skills and negative symptoms, and to a lesser degree positive symptoms. Differential diagnosis can be challenging and discerning expressive and experiential negative symptoms may provide knowledge with potential diagnostic and functional relevance that can guide treatment. Two exploratory factor analyses (EFA) were conducted to reveal the underlying dimensions of negative and positive symptoms using the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Positive Symptoms & Negative Symptoms (SAPS/SANS) and the Autism Diagnostic Observation Schedule-Generic (ADOS-G). Three factors emerged from the negative symptom EFA (70.5 % variance): NF1) Expressive Negative; NF2) Experiential Negative; and NF3) Preoccupation, Absorption & Expressive Affective Flattening. Three positive factors emerged (68.6 % variance): PF1) Hallucinations-Delusions; PF2) Grandiosity; and PF3) Thought Disorder-ADOS positive Symptoms. SZ showed higher PF1 scores, and ASD had higher PF3 scores. No differences between groups were observed in the negative factors. Across groups, all negative factors were inversely associated with quality of life. Only NF1 and NF2 and PF1 were detrimentally related to social functioning. A discriminant function analysis using all factors classified correctly 84.4 % of participants, with PF1, NF1 followed by NF2 being the best predictors of diagnosis. Expressive negative followed by Experiential negative symptoms are of diagnostic value independent of and beyond SZ-related positive symptoms and are related with detrimental functioning. Findings confirm the need to distinctively target negative symptoms, and specific SZ-related and ASD-related positive symptoms, and especially the use of several assessment tools for diagnostic classification.

Remission in schizophrenia spectrum disorders: A randomized trial of amisulpride, aripiprazole and olanzapine

Schizophrenia is a serious mental disorder, and monitoring remission is a widely used measure of effectiveness of the treatment provided. It is very important to identify possible factors correlating with remission. In our substudy of BeSt InTro, a randomized controlled trial of three antipsychotic drugs, 126 patients with ICD-10 diagnoses F20-29 (F23 excluded) were randomized to one of the second-generation antipsychotic drugs amisulpride, aripiprazole or olanzapine. Remission rate was calculated at seven assessment points, with and without using the time criterion of six months included in the consensus remission criteria. Because of drop-out (n = 77), we had data for 49 patients at one-year follow-up. These data were used to calculate the one-year remission rate to 55 % (27/49), without taking into consideration the 6-month time criterion. When we applied the consensus remission criteria with the 6-month time criterion included, the one-year remission rate was calculated for 59 patients: 29 % (17/59). Antipsychotic drug naivety and low negative symptom load at baseline correlated highly with belonging to the remission group. Use of amisulpride was more probable to lead to remission than that of aripiprazole, but it was not more probable than the use of olanzapine (in per-protocol analyses). Negative symptoms showed the largest resistance to treatment. The lack of remission for the majority of the participants in this closely monitored antipsychotic drug trial is alarming and could act as a reminder that novel treatment principles are needed, especially targeted towards the negative symptoms in schizophrenia.

Defeatist performance beliefs in individuals with recent-onset schizophrenia: Relationships with cognition and negative symptoms

BACKGROUND

The cognitive model of negative symptoms of schizophrenia suggests that defeatist performance beliefs (DPB), or overgeneralized negative beliefs about one's performance, are an intermediary variable along the pathway from impaired neurocognitive performance to negative symptoms and functioning in daily life. Although reliable associations between these variables have been established in chronic schizophrenia, less is known about the nature of these relationships in recent-onset schizophrenia (ROSz). This current study tested the associations between DPB and variables in the cognitive model (neurocognitive performance, negative symptoms, functioning) as well as mediation by DPB of the association between neurocognitive performance and negative symptoms in ROSz.

METHODS

A total of 52 participants (32 adults with ROSz and 20 non-psychiatric healthy comparators; HC) completed in-lab measures of neurocognitive performance, self-reported defeatist performance beliefs, and clinician administered measures of negative symptoms and functional outcome. Bivariate relationships among these variables were tested with Pearson correlations. Bootstrapped regression analyses were conducted to test the strength of the indirect effect of neurocognitive performance on negative symptoms through DPB.

RESULTS

Defeatist performance beliefs were significantly elevated in ROSz, and were associated with neurocognitive performance, negative symptoms, and functional outcome as predicted by the cognitive model. There was a significant indirect effect of neurocognition on experiential negative symptoms through DPB, indicating DPB are a partial mediator of the relationship between neurocognitive performance and negative symptoms.

CONCLUSION

These findings are consistent with the cognitive model of negative symptoms and extend previous findings in both ROSz and established schizophrenia. Specifically, these data demonstrate that DPB are elevated among ROSz and the associations with neurocognition and clinical outcomes (e.g., negative symptoms and functioning) are of similar magnitude to those reported in chronic schizophrenia. DPB may therefore be a viable treatment target in the early course of illness.

Intermittent Theta Burst Stimulation Combined with Cognitive Training to Improve Negative Symptoms and Cognitive Impairment in Schizophrenia: A Pilot Study

Schizophrenia is a chronic psychiatric disorder severely affecting patients' functioning and quality of life. Unlike positive symptoms, cognitive impairment and negative symptoms cannot be treated pharmacologically and represent consistent predictors of the illness's prognosis. Cognitive remediation (CR) interventions have been applied to target these symptoms. Brain stimulation also provides promising yet preliminary results in reducing negative symptoms, whereas its effect on cognitive impairment remains heterogeneous. Here, we combined intermittent theta burst stimulation (iTBS) with CR to improve negative symptoms and cognitive impairment in schizophrenia spectrum patients. One hundred eligible patients were invited, and twenty-one participated. We randomized them into four groups, manipulating the stimulation condition (real vs. sham) and CR (no training vs. training). We delivered fifteen iTBS sessions over the left dorsolateral prefrontal cortex for three weeks, followed (or not) by 50 min of training. Consensus-based clinical and cognitive assessment was administered at baseline and after the treatment, plus at three follow-ups occurring one, three, and six months after the intervention. Mixed-model analyses were run on cognitive and negative symptom scores. The preliminary findings highlighted a marginal modulation of iTBS on negative symptoms, whereas CR improved isolated cognitive functions. We herein discuss the limitations and strengths of the methodological approach.

Plasma complement and coagulation proteins as prognostic factors of negative symptoms: An analysis of the NAPLS 2 and 3 studies

INTRODUCTION

Negative symptoms impact the quality of life of individuals with psychosis and current treatment options for negative symptoms have limited effectiveness. Previous studies have demonstrated that complement and coagulation pathway protein levels are related to later psychotic experiences, psychotic disorder, and functioning. However, the prognostic relationship between complement and coagulation proteins and negative symptoms is poorly characterised.

METHODS

In the North American Prodrome Longitudinal Studies 2 and 3, negative symptoms in 431 individuals at clinical high-risk for psychosis (mean age: 18.2, SD 3.6; 42.5 % female) were measured at multiple visits over 2 years using the Scale of Psychosis-Risk Symptoms. Plasma proteins were quantified at baseline using mass spectrometry. Four factors were derived to represent levels of proteins involved in the activation or regulation of the complement or coagulation systems. The relationships between standardised protein group factors and serial measurements of negative symptoms over time were modelled using generalised least squares regression. Analyses were adjusted for baseline candidate prognostic factors: negative symptoms, positive symptoms, functioning, depressive symptoms, suicidal ideation, cannabis use, tobacco use, antipsychotic use, antidepressant use, age, and sex.

RESULTS

Clinical and demographic prognostic factors of follow-up negative symptoms included negative, positive, and depressive symptoms, functioning, and age. Adjusting for all candidate prognostic factors, the complement regulators group and the coagulation regulators group were identified as prognostic factors of follow-up negative symptoms (β: 0.501, 95 % CI: 0.160, 0.842; β: 0.430, 95 % CI: 0.080, 0.780 respectively. The relationship between complement regulator levels and negative symptoms was also observed in NAPLS2 alone (β: 0.501, 95 % CI: -0.037, 1.039) and NAPLS3 alone, additionally adjusting for BMI (β: 0.442, 95 % CI: 0.127, 0.757).

CONCLUSION

The results indicate that plasma complement and coagulation regulator levels are prognostic factors of negative symptoms, independent of clinical and demographic prognostic factors. These results suggest complement and coagulation regulator levels could have potential utility in informing treatment decisions for negative symptoms in individuals at risk.

Environmental factors contributing to negative symptoms in youth at clinical high risk for psychosis and outpatients with schizophrenia

BACKGROUND

A bioecosystem theory was recently proposed positing that negative symptoms of schizophrenia (SZ) are influenced by environmental factors. These environmental processes reflect sources of resource deprivation that manifest across multiple systems that impact individuals directly through microsystems and indirectly through the exosystem and macrosystem. As an initial test of this theory, the current study examined whether self-reported environmental resource deprivation was associated with anhedonia, avolition, and asociality.

METHOD

Two samples were collected: (1) outpatients with schizophrenia or schizoaffective disorder (SZ: n = 38) and matched psychiatrically heathy controls (CN: n = 31); (2) youth at clinical high risk for psychosis (CHR: n = 34) and matched CN (n = 30). Measures of negative symptoms and environmental factors influencing the frequency of recreational, goal-directed, and social activities were collected.

RESULTS

Negative symptoms were associated with environmental deprivation factors in the microsystem (number of social and activity settings) and exosystem (economy, mass media, politics/laws, neighborhood crime). These associations did not appear due to depression and were greater among those with SZ than CHR.

CONCLUSIONS

These findings provide preliminary support for the bioecosystem theory and highlight an under-recognized role for environmental factors underlying negative symptoms across phases of psychotic illness. Environmental systems-focused treatment approaches may offer a novel means of treating negative symptoms, which could be promising when coupled with person-level pharmacological and psychosocial treatments.

COMT and Neuregulin 1 Markers for Personalized Treatment of Schizophrenia Spectrum Disorders Treated with Risperidone Monotherapy

Pharmacogenetic markers are current targets for the personalized treatment of psychosis. Limited data exist on COMT and NRG1 polymorphisms in relation to risperidone treatment. This study focuses on the impact of COMT rs4680 and NRG1 (rs35753505, rs3924999) polymorphisms on risperidone treatment in schizophrenia spectrum disorders (SSDs). This study included 103 subjects with SSD treated with risperidone monotherapy. COMT rs4680, NRG1 rs35753505, and rs3924999 were analyzed by RT-PCR. Participants were evaluated via the Positive and Negative Syndrome Scale (PANSS) after six weeks. Socio-demographic and clinical characteristics were collected. COMT rs4680 genotypes significantly differed in PANSS N scores at admission: AG>AA genotypes (p = 0.03). After six weeks of risperidone, PANSS G improvement was AA>GG (p = 0.05). The PANSS total score was as follows: AA>AG (p = 0.04), AA>GG (p = 0.02). NRG1 rs35753504 genotypes significantly differed across educational levels, with CC>CT (p = 0.02), and regarding the number of episodes, TT>CC, CT>CC (p = 0.01). The PANSS total score after six weeks of treatment showed a better improvement for TT Collapse

Key Words

• COMT
• neuregulin 1
• risperidone monotherapy
• schizophrenia spectrum disorders

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MESH Headings

• Humans
• Neuregulin-1/genetics
• Catechol O-Methyltransferase/genetics
• Risperidone/therapeutic use
• Schizophrenia/drug therapy
• Schizophrenia/genetics
• Male
• Female
• Adult
• Polymorphism, Single Nucleotide
• Antipsychotic Agents/therapeutic use
• Middle Aged
• Precision Medicine/methods
• Genotype

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Affiliation(s)

Mariana Bondrescu Department of Neurosciences-Psychiatry, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.B.); (I.P.) Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.) Doctoral School, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania
Liana Dehelean Department of Neurosciences-Psychiatry, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.B.); (I.P.) Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.)
Simona Sorina Farcas Discipline of Medical Genetics, Department of Microscopic Morphology, Center of Genomic Medicine “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (S.S.F.); (N.I.A.)
Ion Papava Department of Neurosciences-Psychiatry, “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (M.B.); (I.P.) Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.)
Vlad Nicoras Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.)
Dana Violeta Mager Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.)
Anca Eliza Grecescu Timis County Emergency Clinical Hospital “Pius Brinzeu”, Liviu Rebreanu 156, 300723 Timisoara, Romania; (V.N.); (D.V.M.); (A.E.G.)
Petre Adrian Podaru Faculty of Mathematics and Informatics, West University of Timisoara, Vasile Parvan 4, 300223 Timisoara, Romania;
Nicoleta Ioana Andreescu Discipline of Medical Genetics, Department of Microscopic Morphology, Center of Genomic Medicine “Victor Babes” University of Medicine and Pharmacy, Eftimie Murgu Square 2, 300041 Timisoara, Romania; (S.S.F.); (N.I.A.)

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Effects of Visual Art Therapy on Positive Symptoms, Negative Symptoms, and Emotions in Individuals with Schizophrenia: A Systematic Review and Meta-Analysis

Schizophrenia is characterized by psychiatric symptoms and emotional issues. While pharmacological treatments have limitations, non-pharmacological interventions are essential. Art therapy has the potential to enhance emotional expression, communication, and health; however, the effectiveness of visual art therapy remains uncertain. This systematic review and meta-analysis synthesizes the findings of randomized controlled trials (RCTs) of visual art therapy on positive symptoms, negative symptoms, and emotions in patients with schizophrenia. This study reviews RCTs published prior to February, 2024. The PubMed, Embase, Cochrane Library, CEPS, CNKI, Wanfang, and Yiigle databases were searched, and three independent researchers screened the studies. In this meta-analysis, standardized mean difference (SMD) was employed as a measure to calculate effect sizes for continuous variables using a random effects model, while the meta-regression and subgroup analyses were performed with patient and intervention characteristics. A total of 31 studies revealed visual art therapy had a significant small-to-moderate effect on positive symptoms (SMD = 0.407, 95% CI 0.233 to 0.581), a moderate effect on negative symptoms (SMD = 0.697, 95% CI 0.514 to 0.880), a moderate effect on depression (SMD = 0.610, 95% CI 0.398 to 0.821), and a large effect on anxiety (SMD = 0.909, 95% CI 0.386 to 1.433). The subgroup analysis revealed painting and handcrafts had significant effects on positive symptoms, negative symptoms, and emotions. Combined Chinese calligraphy and painting had significant effects on positive symptoms, depression, and anxiety. Better improvement was noted among the Asian population, and a longer weekly treatment duration was associated with better improvement in positive symptoms. Female participants tended to have more improvements in negative symptoms and anxiety through visual art therapy. The results indicate that visual art therapy has positive effects on the psychiatric symptoms and emotions of individuals with schizophrenia. We recommend future research further investigate art therapy modalities and durations.

Current practice for clozapine-induced leukopenia in Japanese psychiatric hospitals: A nationwide survey

Clozapine is an atypical antipsychotic used for treatment-resistant schizophrenia. In Japan, its use requires management by a blood monitoring system called the Clozaril Patient Monitoring Service (CPMS) for the early detection of serious side effects such as agranulocytosis, which is extremely rare. Monitoring services vary among the clozapine suppliers in different countries. Additionally, Japanese patients can be started on clozapine treatment exclusively through an 18-week inpatient admission at a psychiatric hospital capable of coordinating with a hematologist. One reported reason for the lack of widespread clozapine use in Japan is the difficulty in establishing collaboration with hematologists when agranulocytosis/leukopenia occurs. Hence, we conducted a nationwide web-based survey of CPMS-registered psychiatric facilities in Japan to determine the status of collaboration with hematology departments. Valid responses were received from the psychiatrists responsible for prescribing clozapine at 203 of the 547 facilities (response rate: 37.1 %). The largest number of psychiatric facilities (61 %) collaborated with hematologists at another facility with a psychiatry department, while psychiatrists in 32 % of the facilities worked with hematologists at their own facilities. Most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist. The actual workload of hematologists was limited, and the patients might experience the burden of repeated blood sampling. This study suggests that disseminating information regarding the status of collaborations with hematologists may promote the widespread use of clozapine in Japan. SHORT COMMENT FOR TWITTER: This study suggests that most patients with clozapine-induced agranulocytosis/leukopenia could be treated with clozapine discontinuation and follow-up in psychiatric inpatient units with the assistance of a hematologist.

Videogame training increases clinical well-being, attention and hippocampal-prefrontal functional connectivity in patients with schizophrenia

Recent research shows that videogame training enhances neuronal plasticity and cognitive improvements in healthy individuals. As patients with schizophrenia exhibit reduced neuronal plasticity linked to cognitive deficits and symptoms, we investigated whether videogame-related cognitive improvements and plasticity changes extend to this population. In a training study, patients with schizophrenia and healthy controls were randomly assigned to 3D or 2D platformer videogame training or E-book reading (active control) for 8 weeks, 30 min daily. After training, both videogame conditions showed significant increases in sustained attention compared to the control condition, correlated with increased functional connectivity in a hippocampal-prefrontal network. Notably, patients trained with videogames mostly improved in negative symptoms, general psychopathology, and perceived mental health recovery. Videogames, incorporating initiative, goal setting and gratification, offer a training approach closer to real life than current psychiatric treatments. Our results provide initial evidence that they may represent a possible adjunct therapeutic intervention for complex mental disorders.

A 12-month longitudinal naturalistic follow-up of cariprazine in schizophrenia

Background

Cariprazine, a third-generation antipsychotic (TGAs), has demonstrated efficacy in the treatment of schizophrenia with good tolerability profile. Actual real-world literature data are lacking, particularly when exploring its efficacy in the long term. The present study examined the effects of cariprazine treatment on specific psychopathological domains with a particular focus on outcomes and side effects in real-life experience, after a long-term treatment.

Methods

The present 12-month longitudinal naturalistic study included a sample of subjects with a DSM-5-TR diagnosis of schizophrenia, recruited in the outpatients' psychiatric services of university and community hospitals in Italy, naturally treated with cariprazine. The assessments included: a sociodemographic data sheet, the Structured Clinical Interview for the DSM-5 (SCID-5), the Positive and Negative Symptom Scale (PANSS) and the St. Hans Rating Scale (SHRS). The PANSS was also administered after 6 (T1) and 12 (T2) months of treatment with cariprazine while the SHRS at T1.

Results

The total sample consisted of 31 patients, 15 males and 16 females. A significant decrease of the PANSS' subscales, Marder factors and total mean scores emerged at both T1 and T2 with respect to T0. Extrapyramidal symptoms occurred in a minority of patients and in mild or mild/moderate forms: no patient showed moderate forms of psychic/motor akathisia or dystonia, three subjects showed moderate parkinsonism.

Conclusions

This study confirms a good efficacy profile of cariprazine in both positive and negative symptoms in patients with Schizophrenia, combined with a good tolerability profile in extrapyramidal symptoms.

Interaction between catechol-O-methyltransferase Val/Met polymorphism and cognitive reserve for negative symptoms in schizophrenia

BACKGROUND

Cognitive reserve (CR) and the catechol-O-methyltransferase (COMT) Val/Met polymorphism are reportedly linked to negative symptoms in schizophrenia. However, the regulatory effect of the COMT genotype on the relationship between CR and negative symptoms is still unexamined.

AIM

To investigate whether the relationship between CR and negative symptoms could be regulated by the COMT Val/Met polymorphism.

METHODS

In a cross-sectional study, 54 clinically stable patients with schizophrenia underwent assessments for the COMT genotype, CR, and negative symptoms. CR was estimated using scores in the information and similarities subtests of a short form of the Chinese version of the Wechsler Adult Intelligence Scale.

RESULTS

COMT Met-carriers exhibited fewer negative symptoms than Val homozygotes. In the total sample, significant negative correlations were found between negative symptoms and information, similarities. Associations between information, similarities and negative symptoms were observed in Val homozygotes only, with information and similarities showing interaction effects with the COMT genotype in relation to negative symptoms (information, β = -0.282, 95%CI: -0.552 to -0.011, P = 0.042; similarities, β = -0.250, 95%CI: -0.495 to -0.004, P = 0.046).

CONCLUSION

This study provides initial evidence that the association between negative symptoms and CR is under the regulation of the COMT genotype in schizophrenia.

Psychosis spectrum symptoms among individuals with schizophrenia-associated copy number variants and evidence of cerebellar correlates of symptom severity

The 3q29 deletion (3q29Del) is a copy number variant (CNV) with one of the highest effect sizes for psychosis-risk (>40-fold). Systematic research offers avenues for elucidating mechanism; however, compared to CNVs like 22q11.2Del, 3q29Del remains understudied. Emerging findings indicate that posterior fossa abnormalities are common among carriers, but their clinical relevance is unclear. We report the first in-depth evaluation of psychotic symptoms in participants with 3q29Del (N=23), using the Structured Interview for Psychosis-Risk Syndromes, and compare this profile to 22q11.2Del (N=31) and healthy controls (N=279). We also explore correlations between psychotic symptoms and posterior fossa abnormalities. Cumulatively, 48% of the 3q29Del sample exhibited a psychotic disorder or attenuated positive symptoms, with a subset meeting criteria for clinical high-risk. 3q29Del had more severe ratings than controls on all domains and only exhibited less severe ratings than 22q11.2Del in negative symptoms; ratings demonstrated select sex differences but no domain-wise correlations with IQ. An inverse relationship was identified between positive symptoms and cerebellar cortex volume in 3q29Del, documenting the first clinically-relevant neuroanatomical connection in this syndrome. Our findings characterize the profile of psychotic symptoms in the largest 3q29Del sample reported to date, contrast with another high-impact CNV, and highlight cerebellar involvement in psychosis-risk.

The Swedish version of the Motivation and Pleasure Scale self-report (MAP-SR): psychometric properties in patients with schizophrenia or depression

PURPOSE

Negative symptoms are commonly regarded as a symptom dimension belonging to schizophrenia spectrum disorders but are also present in depression. The recently developed Clinical Assessment Interview for Negative Symptoms (CAINS) has shown to be reliable and valid. A corresponding self-report questionnaire has also been developed, named the Motivation and Pleasure Scale - Self Report (MAP-SR). The purpose was to evaluate the psychometric properties of the Swedish version of the MAP-SR in patients with either schizophrenia or depression.

MATERIALS AND METHODS

The MAP-SR was translated to Swedish. Participants were 33 patients with schizophrenia spectrum disorders and 52 patients with a depressive disorder and they completed the MAP-SR, the CAINS and other measures assessing adjacent psychopathology, functioning and cognition.

RESULTS

The internal consistency for the MAP-SR was adequate in both groups (schizophrenia spectrum α = .93, depressive disorder α = .82). Furthermore, the MAP-SR had a large correlation to the motivation and pleasure subscale of the CAINS in patients with schizophrenia disorders (r = -0.75, p < .001), however among patients with depression this correlation was medium-to-large (r = -0.48, p < 0.001).

CONCLUSIONS

Findings suggest that the Swedish version of the MAP-SR shows promise as a useful measure of motivation and pleasure, especially in patients with schizophrenia spectrum disorders. Furthermore, results also suggest that the MAP-SR does not assess negative symptoms specifically, but that there is an overlap between depressive and negative symptoms.

Psychosis superspectrum II: neurobiology, treatment, and implications

Alternatives to traditional categorical diagnoses have been proposed to improve the validity and utility of psychiatric nosology. This paper continues the companion review of an alternative model, the psychosis superspectrum of the Hierarchical Taxonomy of Psychopathology (HiTOP). The superspectrum model aims to describe psychosis-related psychopathology according to data on distributions and associations among signs and symptoms. The superspectrum includes psychoticism and detachment spectra as well as narrow subdimensions within them. Auxiliary domains of cognitive deficit and functional impairment complete the psychopathology profile. The current paper reviews evidence on this model from neurobiology, treatment response, clinical utility, and measure development. Neurobiology research suggests that psychopathology included in the superspectrum shows similar patterns of neural alterations. Treatment response often mirrors the hierarchy of the superspectrum with some treatments being efficacious for psychoticism, others for detachment, and others for a specific subdimension. Compared to traditional diagnostic systems, the quantitative nosology shows an approximately 2-fold increase in reliability, explanatory power, and prognostic accuracy. Clinicians consistently report that the quantitative nosology has more utility than traditional diagnoses, but studies of patients with frank psychosis are currently lacking. Validated measures are available to implement the superspectrum model in practice. The dimensional conceptualization of psychosis-related psychopathology has implications for research, clinical practice, and public health programs. For example, it encourages use of the cohort study design (rather than case-control), transdiagnostic treatment strategies, and selective prevention based on subclinical symptoms. These approaches are already used in the field, and the superspectrum provides further impetus and guidance for their implementation. Existing knowledge on this model is substantial, but significant gaps remain. We identify outstanding questions and propose testable hypotheses to guide further research. Overall, we predict that the more informative, reliable, and valid characterization of psychopathology offered by the superspectrum model will facilitate progress in research and clinical care.

Effectiveness of information technology assisted relapse prevention program on relapse among people who live with severe mental disorders

BACKGROUND

Severe Mental Disorders (SMDs) cause mental health worldwide challenges because of several relapses and extensive recovery periods of hospitalization, which put a lot of economic and social burden on families and governments. Therefore, interventions are necessary to decrease the relapse of these disorders.

AIM

This study was conducted to investigate the effect of Information Technology Assisted Relapse Prevention Program (ITAREP) on relapse among people who live with SMDs.

METHOD

This study was a randomized clinical trial with intervention and control groups. ITAREP is a remote intervention based on monitoring the Early Warning Signs (EWS) to decrease the number of potential relapses. Using convenience sampling, people with SMDs admitted to Sina Juneqan Psychiatric Hospital and their caregivers were recruited in this study and randomly allocated to the control and intervention groups. Two checklists of the EWS for the patient and the patient's caregiver were used for monitoring the relapse signs. Data were collected at baseline and 90 days after discharge and were analyzed using t-test and Chi-square statistical tests and linear regression in SPSS software.

RESULTS

Fifty-two patients who lived with SMDs participated in this study (26 in the intervention group and 26 in the control group). The two groups were homogeneous regarding age, gender, type of mental disorder, and duration of the disorder. Forty-two males and ten females participated in this research. Most of the participants were diagnosed with schizophrenia. The results showed that the number of relapses in the intervention group was significantly lower than in the control group in the post-test.

CONCLUSION

Social workers, as the case managers and a member of the interdisciplinary psychiatric team, can actively perform follow-up measures after discharge using ITAREP, and it can be expected that these interventions will reduce the number of relapses among patients who live with SMDs.

Systematic Review and Meta-analysis of Exercise Interventions for Psychotic Disorders: The Impact of Exercise Intensity, Mindfulness Components, and Other Moderators on Symptoms, Functioning, and Cardiometabolic Health

BACKGROUND AND HYPOTHESIS

Exercise therapy has been shown to be an effective complementary treatment for patients with psychotic disorders. However, the specific impacts of different training modalities remain poorly understood. This article aims to quantitatively review the moderating influence of different exercise modalities, hypothesizing that higher exercise intensity as well as utilization of mindfulness-based exercise (MBE) components, will improve intervention outcomes.

STUDY DESIGN

PubMed, Web of Science, and PsycINFO were searched from 2010 to March 2022 for randomized controlled trials investigating exercise interventions in patients with psychotic disorders (preregistration: https://doi.org/10.17605/OSF.IO/J8QNS). Outcomes considered were positive/negative symptoms, Positive and Negative Syndrome Scale (PANSS) General Psychopathology/Total scores, depressive symptoms, psychosocial functioning, quality of life, cardiorespiratory fitness, and body mass index. Separate meta-analyses, including moderator analyses, were performed to evaluate the moderating influence of different training modalities.

STUDY RESULTS

Of 6653 studies, 40 (n = 2111 patients) were included in the meta-analysis. The effects of moderate-intensity exercise exceed low-intensity approaches for PANSS Total scores (P = .02) and depressive symptoms (P = .04). The presence of MBE components was associated with improvements in positive symptoms (P = .04) and PANSS General Psychopathology subscores (P = .04) but also with higher error and between-study heterogeneity. Our analysis also shows improved intervention effects on depression in younger patients (P = .012) and improved psychosocial functioning scores following more frequent sessions (P < .01).

CONCLUSIONS

A minimum of moderate intensity should be considered. More frequent training sessions per week also seem to be beneficial. While adding mindfulness elements is promising, it increases heterogeneity and requires caution in terms of generalization.