1
|
Bejerot S, Eklund D, Hesser H, Hietala MA, Kariis T, Lange N, Lebedev A, Montgomery S, Nordenskjöld A, Petrovic P, Söderbergh A, Thunberg P, Wikström S, Humble MB. Study protocol for a randomized controlled trial with rituximab for psychotic disorder in adults (RCT-Rits). BMC Psychiatry 2023; 23:771. [PMID: 37872497 PMCID: PMC10594806 DOI: 10.1186/s12888-023-05250-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023] Open
Abstract
BACKGROUND The role of inflammation in the aetiology of schizophrenia has gained wide attention and research on the association shows an exponential growth in the last 15 years. Autoimmune diseases and severe infections are risk factors for the later development of schizophrenia, elevated inflammatory markers in childhood or adolescence are associated with a greater risk of schizophrenia in adulthood, individuals with schizophrenia have increased levels of pro-inflammatory cytokines compared to healthy controls, and autoimmune diseases are overrepresented in schizophrenia. However, treatments with anti-inflammatory agents are so far of doubtful clinical relevance. The primary objective of this study is to test whether the monoclonal antibody rituximab, directed against the B-cell antigen CD20 ameliorates psychotic symptoms in adults with schizophrenia or schizoaffective disorder and to examine potential mechanisms. A secondary objective is to examine characteristics of inflammation-associated psychosis and to identify pre-treatment biochemical characteristics of rituximab responders. A third objective is to interview a subset of patients and informants on their experiences of the trial to obtain insights that rating scales may not capture. METHODS A proof-of-concept study employing a randomised, parallel-group, double-blind, placebo-controlled design testing the effect of B-cell depletion in patients with psychosis. 120 participants with a diagnosis of schizophrenia spectrum disorders (SSD) (ICD-10 codes F20, F25) will receive either one intravenous infusion of rituximab (1000 mg) or saline. Psychiatric measures and blood samples will be collected at baseline, week 12, and week 24 post-infusion. Brief assessments will also be made in weeks 2 and 7. Neuroimaging and lumbar puncture, both optional, will be performed at baseline and endpoints. Approximately 40 of the patients and their informants will be interviewed for qualitative analyses on the perceived changes in well-being and emotional qualities, in addition to their views on the research. DISCUSSION This is the first RCT investigating add-on treatment with rituximab in unselected SSD patients. If the treatment is helpful, it may transform the treatment of patients with psychotic disorders. It may also heighten the awareness of immune-psychiatric disorders and reduce stigma. TRIAL REGISTRATION NCT05622201, EudraCT-nr 2022-000220-37 version 2.1. registered 14th of October 2022.
Collapse
Affiliation(s)
- Susanne Bejerot
- Faculty of Health and Medical Sciences, University Health Care Research Centre, Örebro University, Örebro, Sweden.
| | - Daniel Eklund
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Hugo Hesser
- School of Behavioural, Social and Legal Sciences, Örebro University, Örebro, Sweden
| | - Max Albert Hietala
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tarmo Kariis
- Karlstad Central Hospital, Region Värmland, Karlstad, Sweden
| | - Niclas Lange
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Alexander Lebedev
- Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Scott Montgomery
- Clinical Epidemiology and Biostatistics, School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Axel Nordenskjöld
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Predrag Petrovic
- Center for Psychiatry Research (CPF), Center for Cognitive and Computational Neuropsychiatry (CCNP), Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Söderbergh
- Department of Rheumatology, Örebro University Hospital, Örebro, Sweden
| | - Per Thunberg
- Department of Radiology and Medical Physics, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
- Center for Experimental and Biomedical Imaging in Örebro (CEBIO), Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Sverre Wikström
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
- Centre for Clinical Research, County Council of Värmland, Karlstad, Sweden
| | - Mats B Humble
- Faculty of Medicine and Health, School of Medical Sciences, Örebro University, Örebro, Sweden
| |
Collapse
|
2
|
Suneson K, Grudet C, Ventorp F, Malm J, Asp M, Westrin Å, Lindqvist D. An inflamed subtype of difficult-to-treat depression. Prog Neuropsychopharmacol Biol Psychiatry 2023; 125:110763. [PMID: 37037323 DOI: 10.1016/j.pnpbp.2023.110763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 04/03/2023] [Accepted: 04/06/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Chronic low-grade inflammation may play a role in the pathophysiology of depression, at least in a subset of patients. High-sensitivity C-reactive protein (hs-CRP) has been used to define an inflamed subgroup of depression with specific clinical characteristics and symptoms. In this study we investigated biochemical and clinical characteristics in patients with difficult-to-treat depression with and without chronic low-grade inflammation. METHOD We assayed plasma levels of interferon-gamma, tumor necrosis factor-alpha, Interleukin (IL)-10, IL-6, IL-8, and vitamin D in a clinically well-characterized sample of patients with difficult-to-treat depression (n = 263) and healthy controls (n = 46). Serum hs-CRP levels were available in the patient group and were used to define "inflamed depression" (hs-CRP > 3 mg/L). Based on previous studies correlating specific depressive symptoms to inflammatory markers, we calculated a composite score of inflammatory depressive symptoms (Infl-Dep score). A principal component analysis (PCA) was performed to identify patterns of variance in cytokines and vitamin D among patients. RESULTS Mean levels of IL-6 and IL-8 were significantly higher in depressed patients compared to controls, also after adjusting for sex, smoking, BMI, and age. None of the other inflammatory markers differed significantly between depressed patients and controls. Two components were extracted using PCA; one showed general cytokine elevations and one represented a pattern where IL-6 and IL-8 were inversely related to vitamin D (IL6-IL8-VitD component). The inflamed subgroup (hs-CRP > 3, n = 51) exhibited significantly higher BMI, higher Infl-Dep scores and higher IL6-IL8-VitD component scores than uninflamed patients (hs-CRP ≤ 3, n = 212). There were no significant differences in overall depression severity or suicidality between the inflamed and uninflamed groups. CONCLUSION Our results support the hypothesis of an inflamed subgroup of depression as a meaningful construct. This subgroup may have certain biological and clinical characteristics and more studies are needed to determine potential clinical implications.
Collapse
Affiliation(s)
- Klara Suneson
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden; Office for Psychiatry and Habilitation, Psychiatric Clinic Helsingborg, Region Skåne, 252 23 Helsingborg, Sweden
| | - Cécile Grudet
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden
| | - Filip Ventorp
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden; Office for Psychiatry and Habilitation, Psychiatric Clinic Lund, Region Skåne, 221 85 Lund, Sweden
| | - Johan Malm
- Department of Translational Medicine, Lund University, Skåne University Hospital, 205 02, Malmö, Sweden
| | - Marie Asp
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden; Office for Psychiatry and Habilitation, Psychiatric Clinic Lund, Region Skåne, 221 85 Lund, Sweden
| | - Åsa Westrin
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden; Office for Psychiatry and Habilitation, Psychiatry Research Skåne, Region Skåne, 221 85 Lund, Sweden
| | - Daniel Lindqvist
- Department of Clinical Sciences Lund, Psychiatry, Faculty of Medicine, Lund University, 221 85 Lund, Sweden; Office for Psychiatry and Habilitation, Psychiatry Research Skåne, Region Skåne, 221 85 Lund, Sweden.
| |
Collapse
|
3
|
Bejerot S, Sigra Stein S, Welin E, Eklund D, Hylén U, Humble MB. Rituximab as an adjunctive treatment for schizophrenia spectrum disorder or obsessive-compulsive disorder: Two open-label pilot studies on treatment-resistant patients. J Psychiatr Res 2023; 158:319-329. [PMID: 36638622 DOI: 10.1016/j.jpsychires.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/04/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022]
Abstract
In this explorative study, we investigated if an adjunctive treatment with one single dose of the monoclonal antibody rituximab would improve symptoms and function in treatment-resistant patients with schizophrenia spectrum disorder (SSD, n = 9) or obsessive-compulsive disorder (OCD, n = 10), based on the inflammatory hypothesis for mental disorders. Patients were followed for one year. Disability was measured with the Personal and Social Performance score (PSP). At baseline, the mean PANSS score in the SSD group was 99 ± 32 and the mean Y-BOCS score in the OCD group was 27.5 ± 7. Mean PSP scores were 32 ± 10.2 and 42.5 ± 9.9 in the SSD and OCD groups, respectively. Seven had Paediatric Acute-Onset Neuropsychiatric Syndrome (PANS) in retrospect, and 3 SSD patients had schizo-obsessive subtype. 4/8 SSD patients showed a ≥40% reduction in PANSS at endpoint I week 20, however, 7/9 were similarly improved already at week 12. Among the OCD patients, 2/10 showed a ≥35% reduction in Y-BOCS at week 20. Disability was significantly improved only in the SSD group. The percentual decrease of PANSS scores in SSD patients was associated with the increase in immunoglobulin levels week 20 (n = 8: IgG r = 0.85, p = .007; IgA r = 0.79, p = .019; IgM r = 0.73, p = .038). Rituximab was generally well tolerated in these patients. Self-rated improvements since baseline were reported for psychic (p = .021), neurological (p = .059), and autonomic (p < .001) side effects (UKU-SERS-Pat side-effect scale). Anxiety was commonly reported by OCD patients, while an initial increase in psychotic symptoms was seen in a few SSD patients. An RCT is underway to evaluate rituximab in SSD.
Collapse
Affiliation(s)
- Susanne Bejerot
- School of Medical Sciences, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden; Inflammatory Response and Infection Susceptibility Centre, (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Sofia Sigra Stein
- School of Medical Sciences, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden.
| | - Elisabet Welin
- School of Health Sciences, Örebro University, Örebro, Sweden.
| | - Daniel Eklund
- School of Medical Sciences, Örebro University, Örebro, Sweden; Inflammatory Response and Infection Susceptibility Centre, (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Ulrika Hylén
- School of Medical Sciences, Örebro University, Örebro, Sweden; University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Sweden; Inflammatory Response and Infection Susceptibility Centre, (iRiSC), Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
| | - Mats B Humble
- School of Medical Sciences, Örebro University, Örebro, Sweden.
| |
Collapse
|
4
|
Sartin-Tarm A, Lorenz T. Sexual Trauma Moderates Hormonal Mediators of Women’s Sexual Function. CURRENT SEXUAL HEALTH REPORTS 2022. [DOI: 10.1007/s11930-022-00337-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
5
|
González-Rodríguez A, Monreal JA, Natividad M, Seeman MV. Collaboration between Psychiatrists and Other Allied Medical Specialists for the Treatment of Delusional Disorders. Healthcare (Basel) 2022; 10:healthcare10091729. [PMID: 36141341 PMCID: PMC9498439 DOI: 10.3390/healthcare10091729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 09/06/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background: There is increasing evidence that individuals with psychosis are at increased risk for cardiovascular disease, diabetes, metabolic syndrome, and several other medical comorbidities. In delusional disorder (DD), this is particularly so because of the relatively late onset age. Aims: The aim of this narrative review is to synthesize the literature on the necessity for medical collaboration between psychiatrists and other specialists. Methods: A non-systematic narrative review was carried out of papers addressing referrals and cooperation among specialists in the care of DD patients. Results: Psychiatrists, the primary care providers for DD patients, depend on neurology to assess cognitive defects and rule out organic sources of delusions. Neurologists rely on psychiatry to help with patient adherence to treatment and the management of psychotropic drug side effects. Psychiatrists require ophthalmology/otolaryngology to treat sensory deficits that often precede delusions; reciprocally, psychiatric consults can help in instances of functional sensory impairment. Close collaboration with dermatologists is essential for treating delusional parasitosis and dysmorphophobia to ensure timely referrals to psychiatry. Conclusions: This review offers many other examples from the literature of the extent of overlap among medical specialties in the evaluation and effective treatment of DD. Optimal patient care requires close collaboration among specialties.
Collapse
Affiliation(s)
- Alexandre González-Rodríguez
- Department of Mental Health, Mutua Terrassa University Hospital, 5 Dr. Robert Square, 08221 Terrassa, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona, 08221 Terrassa, Spain
| | - José Antonio Monreal
- Department of Mental Health, Mutua Terrassa University Hospital, 5 Dr. Robert Square, 08221 Terrassa, Spain
- Centro de Investigación Biomédica en Red de Salud Mental (CIBERSAM), University of Barcelona, 08221 Terrassa, Spain
- Institut de Neurociències, Universitat Autònoma de Barcelona (UAB), 08221 Terrassa, Spain
- Correspondence:
| | - Mentxu Natividad
- Department of Mental Health, Mutua Terrassa University Hospital, 5 Dr. Robert Square, 08221 Terrassa, Spain
| | - Mary V. Seeman
- Department of Psychiatry, University of Toronto, 605 260 Heath Street West, Toronto, ON M5P 3L6, Canada
| |
Collapse
|
6
|
Bayassi-Jakowicka M, Lietzau G, Czuba E, Patrone C, Kowiański P. More than Addiction—The Nucleus Accumbens Contribution to Development of Mental Disorders and Neurodegenerative Diseases. Int J Mol Sci 2022; 23:ijms23052618. [PMID: 35269761 PMCID: PMC8910774 DOI: 10.3390/ijms23052618] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 01/09/2023] Open
Abstract
Stress and negative emotions evoked by social relationships and working conditions, frequently accompanied by the consumption of addictive substances, and metabolic and/or genetic predispositions, negatively affect brain function. One of the affected structures is nucleus accumbens (NAc). Although its function is commonly known to be associated with brain reword responses and addiction, a growing body of evidence also suggests its role in some mental disorders, such as depression and schizophrenia, as well as neurodegenerative diseases, such as Alzheimer’s, Huntington’s, and Parkinson’s. This may result from disintegration of the extensive connections based on numerous neurotransmitter systems, as well as impairment of some neuroplasticity mechanisms in the NAc. The consequences of NAc lesions are both morphological and functional. They include changes in the NAc’s volume, cell number, modifications of the neuronal dendritic tree and dendritic spines, and changes in the number of synapses. Alterations in the synaptic plasticity affect the efficiency of synaptic transmission. Modification of the number and structure of the receptors affects signaling pathways, the content of neuromodulators (e.g., BDNF) and transcription factors (e.g., pCREB, DeltaFosB, NFκB), and gene expression. Interestingly, changes in the NAc often have a different character and intensity compared to the changes observed in the other parts of the basal ganglia, in particular the dorsal striatum. In this review, we highlight the role of the NAc in various pathological processes in the context of its structural and functional damage, impaired connections with the other brain areas cooperating within functional systems, and progression of the pathological processes.
Collapse
Affiliation(s)
- Martyna Bayassi-Jakowicka
- Division of Anatomy and Neurobiology, Faculty of Medicine, Medical University of Gdańsk, Dębinki 1, 80-211 Gdansk, Poland; (M.B.-J.); (E.C.)
| | - Grazyna Lietzau
- Division of Anatomy and Neurobiology, Faculty of Medicine, Medical University of Gdańsk, Dębinki 1, 80-211 Gdansk, Poland; (M.B.-J.); (E.C.)
- Correspondence: (G.L.); (P.K.); Tel.: +48-58-349-14-01 (G.L. & P.K.)
| | - Ewelina Czuba
- Division of Anatomy and Neurobiology, Faculty of Medicine, Medical University of Gdańsk, Dębinki 1, 80-211 Gdansk, Poland; (M.B.-J.); (E.C.)
| | - Cesare Patrone
- Department of Clinical Science and Education, Södersjukhuset, Internal Medicine, Karolinska Institutet, Sjukhusbacken 17, 11883 Stockholm, Sweden;
| | - Przemysław Kowiański
- Division of Anatomy and Neurobiology, Faculty of Medicine, Medical University of Gdańsk, Dębinki 1, 80-211 Gdansk, Poland; (M.B.-J.); (E.C.)
- Correspondence: (G.L.); (P.K.); Tel.: +48-58-349-14-01 (G.L. & P.K.)
| |
Collapse
|
7
|
Introduction. Harv Rev Psychiatry 2022; 30:1-3. [PMID: 34995030 PMCID: PMC8812237 DOI: 10.1097/hrp.0000000000000324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|