Clinical correlates of vitamin D deficiency in established psychosis

Diminished social motivation in early psychosis is associated with polygenic liability for low vitamin D

Insufficiency of vitamin D levels often occur in individuals with schizophrenia and first-episode psychosis (FEP). However, it is unknown whether this represents a biological predisposition, or it is essentially driven by illness-related alterations in lifestyle habits. Lower vitamin D has also been associated with adverse neurodevelopmental outcomes and predominant negative psychotic symptoms. This study aimed to investigate the contribution of polygenic risk score for circulating 25-hydroxyvitamin D concentration (PRS-vitD) to symptom presentation among individuals with FEP enrolled in the Athens First-Episode Psychosis Research Study (AthensFEP n = 205) and the Psychosis Incident Cohort Outcome Study (PICOS n = 123). The severity of psychopathology was evaluated using the Positive and Negative Syndrome Scale at baseline and follow-up assessments (AthensFEP: 4-weeks follow-up, PICOS: 1-year follow-up). Premorbid intelligence and adjustment domains were also examined as proxy measures of neurodevelopmental deviations. An inverse association between PRS-vitD and severity of negative symptoms, in particular lack of social motivation, was detected in the AthensFEP at baseline (adjusted R2 = 0.04, p < 0.001) and follow-up (adjusted R2 = 0.03, p < 0.01). The above observation was independently validated in PICOS at follow-up (adjusted R2 = 0.06, p < 0.01). No evidence emerged for a relationship between PRS-vitD and premorbid measures of intelligence and adjustment, likely not supporting an impact of lower PRS-vitD on developmental trajectories related to psychotic illness. These findings suggest that polygenic vulnerability to reduced vitamin D impairs motivation and social interaction in individuals with FEP, thereby interventions that encourage outdoor activities and social engagement in this patient group might attenuate enduring negative symptoms.

Genome-wide Association Analysis of Schizophrenia and Vitamin D Levels Shows Shared Genetic Architecture and Identifies Novel Risk Loci

Low vitamin D (vitD) levels have been consistently reported in schizophrenia (SCZ) suggesting a role in the etiopathology. However, little is known about the role of underlying shared genetic mechanisms. We applied a conditional/conjunctional false discovery rate approach (FDR) on large, nonoverlapping genome-wide association studies for SCZ (N cases = 53 386, N controls = 77 258) and vitD serum concentration (N = 417 580) to evaluate shared common genetic variants. The identified genomic loci were characterized using functional analyses and biological repositories. We observed cross-trait SNP enrichment in SCZ conditioned on vitD and vice versa, demonstrating shared genetic architecture. Applying the conjunctional FDR approach, we identified 72 loci jointly associated with SCZ and vitD at conjunctional FDR < 0.05. Among the 72 shared loci, 40 loci have not previously been reported for vitD, and 9 were novel for SCZ. Further, 64% had discordant effects on SCZ-risk and vitD levels. A mixture of shared variants with concordant and discordant effects with a predominance of discordant effects was in line with weak negative genetic correlation (rg = -0.085). Our results displayed shared genetic architecture between SCZ and vitD with mixed effect directions, suggesting overlapping biological pathways. Shared genetic variants with complex overlapping mechanisms may contribute to the coexistence of SCZ and vitD deficiency and influence the clinical picture.

The causal effect of schizophrenia on fractures and bone mineral density: a comprehensive two-sample Mendelian randomization study of European ancestry

BACKGROUND

Schizophrenia was clinically documented to co-occur with fractures and aberrant bone mineral density (BMD), but the potential causal relationship remained unclear. This study aimed to test the causal effects between schizophrenia and fractures as well as aberrant BMD by conducting Mendelian randomization (MR) analyses.

METHODS

Two-sample MR was utilized, based on instrumental variables from large genome-wide association studies (GWAS) of schizophrenia as exposure, to identify the causal association of schizophrenia with mixed fractures, fractures at different body sites (including skull and facial bones, shoulder and upper arm, wrist and hand, and femur) and BMDs of forearm (FA), femoral neck (FN), lumbar spine (LS) and estimated BMD (eBMD). Multivariable Mendelian randomization (MVMR) analysis was performed to minimize the confounding effect of body mass index (BMI).

RESULTS

Result from inverse variance weighting (IVW) method provided evidence schizophrenia increased the risk of fractures of skull and facial bones [odds ratio (OR) = 1.0006, 95% confidence interval (CI): 1.0003 to 1.0010] and femur [OR =1.0007, 95% CI: 1.0003 to 1.0011], whereas, decreased the level of eBMD [β (95%CI): -0.013 (-0.021, -0.004)]. These causal effects still existed after adjusting for BMI. Sensitivity analyses showed similar results. However, no causal effect of schizophrenia on fracture or BMD in other parts was detected.

CONCLUSION

The current finding confirmed that schizophrenia was causally associated with the fractures of skull, face and femur as well as eBMD, which might remind psychiatrists to pay close attention to the fracture risk in schizophrenic patients when formulating their treatment strategies.

Characterization of Hip Fractures Among Adults With Schizophrenia in Ontario, Canada

Importance

Evidence suggests that individuals with schizophrenia are at an increased risk of hip fractures; however, the sex-specific burden of hip fractures among adults with schizophrenia has not been quantified and compared with the general population.

Objective

To describe sociodemographic and clinical characteristics of patients with hip fracture and schizophrenia and to quantify their sex-specific annual hip fracture rates relative to those without schizophrenia.

Design, Setting, and Participants

This repeated population-based, cross-sectional study leveraged multiple individually linked health administrative databases for patients in Ontario, Canada. We included patients aged 40 to 105 years with hip fracture-related hospitalization between April 1, 2009, and March 31, 2019. Statistical analysis was performed between November 2021 and February 2023.

Exposure

Schizophrenia diagnosis, ascertained using a validated algorithm.

Main Outcomes and Measures

The main outcome was sex-specific age-standardized annual hip fracture rate per 10 000 individuals and annual percent change in age-standardized rates. Rates were direct adjusted to the 2011 Ontario population, and joinpoint regression analysis was performed to evaluate annual percent change.

Results

We identified 117 431 hip fracture records; of these, there were 109 908 index events. Among the 109 908 patients with hip fracture, 4251 had schizophrenia and 105 657 did not. Their median age was 83 years (IQR, 75-89 years), and 34 500 (31.4%) were men. Patients with hip fracture and schizophrenia were younger at the index event compared with those without schizophrenia. Men had a median age of 73 vs 81 years (IQR, 62-83 vs 71-87 years; standardized difference, 0.46), and women had a median age of 80 vs 84 years (IQR, 71-87 vs 77-89 years; standardized difference, 0.32). A higher proportion of patients with vs without schizophrenia had frailty (53.7% vs 34.2%; standardized difference, 0.40) and previous fragility fractures (23.5% vs 19.1%; standardized difference, 0.11). The overall age-standardized rate per 10 000 individuals with vs without schizophrenia was 37.5 (95% CI, 36.4 to 38.6) vs 16.0 (95% CI, 15.9 to 16.1). Age-standardized rates were 3-fold higher in men with vs without schizophrenia (31.0 [95% CI, 29.5 to 32.6] vs 10.1 [95% CI, 10.0 to 10.2]) and more than 2-fold higher in women with vs without schizophrenia (43.4 [95% CI, 41.9 to 44.9] vs 21.4 [95% CI, 21.3 to 21.6]). Overall, joinpoint regression analysis identified a steady annual decrease of 0.7% (95% CI, -1.1% to -0.3%) in age-standardized rates for both study groups.

Conclusions and Relevance

The findings of this cross-sectional study suggest that individuals with schizophrenia experience an earlier age of onset and considerably higher rate of hip fractures compared with the general population, with implications for targeted fracture prevention and optimization of clinical bone health management over the course of their psychiatric illness.

Vitamin D Deficiency and Risk Factors Related to Acute Psychiatric Relapses in Patients with Severe Mental Disorders: A Preliminary Study

Previous studies have indicated that vitamin (Vit) D deficiency is frequent in psychiatric patients, regardless of diagnostic category. We aimed to assess whether acute psychiatric relapses in inpatients was associated with Vit D deficiency compared to stabilized outpatients. The cohort (152 total patients, 75 males and 77 females) had a mean age of 47.3 ± 14.4 years at admission and was grouped according to psychiatric diagnosis. Psychopathological symptom severity was assessed by the Brief Psychiatric Rating Scale (BPRS), a multidimensional symptom inventory. Total calcium serum levels were measured using standard laboratory methods, while plasma levels of 25-OH-Vit D and parathyroid hormone (PTH) were measured by automated chemiluminescence immunoassays. The psychiatric inpatient subgroup showed a significant difference in serum levels of 25-OH-Vit D and PTH (p < 0.001). Correlation analysis between serum levels of 25-OH-Vit D and BPRS total and subitem scores indicated a significantly negative relationship. In addition, linear regression analysis evidenced that the inpatient condition might predict low PTH and 25-OH-Vit D serum levels. Hospitalized psychiatric patients are at increased risk for Vit D deficiency regardless of their diagnostic categories. The mechanism underlying the association between acute psychiatric relapses and Vit D deficiency remains unclear. Therefore, screening for Vit D deficiency should pertain to the health assessment of patients with major psychiatric disorders.

Neutropenia in Patients With Clozapine-Treated Schizophrenia: An Effect of Clozapine or a Consequence of SARS-CoV-2 Infection? A Systematic Review

BACKGROUND

Clozapine is the only approved antipsychotic for treatment-resistant schizophrenia. Despite its therapeutic benefits, it is still widely underused, mainly because of its potential to cause agranulocytosis and neutropenia. Prescribing clozapine in COVID-19-positive patients became more challenging because of this potential side effect. This article is a review of literature on the risk of neutropenia associated with clozapine treatment in patients with COVID-19.

AREAS OF UNCERTAINTY

In clozapine-treated COVID-19-positive patients, neutropenia was reported in some cases; is it a consequence of clozapine treatment or of SARS-Co2 infection?

DATA SOURCES

Data were extracted from 2 databases: PubMed/MEDLINE and Google Scholar. We selected all original reports, from March 2020 until May 2022, on neutropenia associated with clozapine treatment in positive COVID-19 patients. Eleven studies were selected for the final analysis.

THERAPEUTIC ADVANCES

Before the COVID-19 pandemic, neutropenia in clozapine-treated patients was reported in 3.8% of cases. During the pandemic, neutropenia rates seemed to be higher. As per the cause of neutropenia, studies reported contradictory results. We aim to clarify rates and causes of neutropenia in clozapine-treated COVID-19-positive patients.

RESULTS

Three hundred eighty-eight articles were initially selected from the 2 databases. After excluding duplicates, unrelated articles, reviews, and guidelines, 11 studies were analyzed, all centered on clozapine treatment, COVID-19 infection, and associated neutropenia.

CONCLUSIONS

Clozapine treatment in COVID-19-positive patients may be associated with a transient reduction of absolute neutrophils count, in some cases reaching neutropenia levels. Neutropenia rates reported in SARS-CoV-2-infected patients are higher than the prepandemic reports; therefore, we assume that the cause might be a result of the immunological interference between clozapine and SARS-CoV-2. Clozapine treatment needs to be continued whenever possible, with dose adjustments in relation to blood test results.

Golden opportunity for intervention? Identifying vitamin D deficiency in patients with substance use disorders in hospital

Setting

Based at a busy city hospital, the alcohol care team is a drug and alcohol specialist service, taking referrals for a wide range of patients with substance use disorders (SUD).

Objectives

Patients with SUD are at high risk of vitamin D deficiency; this relates to frequent fractures and proximal myopathy. The coronavirus pandemic brought vitamin D into focus. Local guidelines advise that patients at high risk of vitamin D deficiency are offered replacement. There were no local data on vitamin D deficiency prevalence or any mention of patients with SUD in local vitamin D guidelines. The main aim of this project was to offer vitamin D checks and replacement to all appropriate patients.

Results

We collected data on 207 patients, [pilot study (n=50) and two subsequent samples (n=95 and n=62)]. Our pilot study showed that no patients were offered vitamin D testing or replacement. We then offered vitamin D checks to 95 patients. Most had low vitamin D (30 patients were vitamin D deficient and 26 were vitamin D insufficient). We provided vitamin D replacement and follow-up advice. Quality improvement was demonstrated 6 months later. We collected data on a further 62 patients who were all on our current or recent caseload. Following exclusions, nearly half (48%) of patients had had a vitamin D check. Almost all of these (95%) had low vitamin D (60% being classified as deficient).

Conclusions

Patients had not been offered vitamin D replacement despite often having multiple risk factors for vitamin D deficiency. Vitamin D checks (and subsequent replacement) rose in frequency since the outset of this project. Local guidelines should add SUD as a risk factor for vitamin D deficiency. Hospital admission provides a rich opportunity to offer this simple intervention to patients who are often poorly engaged with community services.

Clozapine and Neutropenia in Patients with Schizophrenia and SARS-CoV-2 Infection

BACKGROUND

Clozapine (CLZ) is used for treatment-resistant schizophrenia (TRS). Adverse reactions to clozapine include neutropenia. In March 2020, WHO declared the COVID-19 pandemic and after, psychiatrists raised concerns regarding continuation of clozapine, due to multiple restrictions. We aimed to provide a study on the association between neutropenia and clozapine in patients with schizophrenia and COVID-19.

AIM

To assess the neutrophil count in patients with schizophrenia treated with clozapine and infected with COVID-19.

METHODS

The study patients with schizophrenia, according to DSM-5, admitted to the Clinical Hospital of Psychiatry and Neurology Brasov, Romania, between April 2020 and October 2021. The inclusion criteria included positive RT-PCR (real-time PCR) test for COVID-19 and treatment with clozapine. We assessed three values of ANC (absolute neutrophil count): before COVID-19 infection (last ANC obtained at mandatory check), during infection and 1 month after resolution (first negative PCR test).

RESULTS

Of the 105 cases, 95 did not have neutropenia. Fifty-nine patients were males (62.1%), mean age was 43.5 years (SD = 12.1) with an average of clozapine treatment of 52.4 months (SD = 11.9). At baseline, they had a small reduction in the ANC mean value (4.41 × 109/l; SD = 2.22) which did not constitute a statistically significant decline from the prior to COVID-19 mean value of 4.66 × 109/l (SD = 2.34; p = 0.45). Values were also normal in the first month after negative PCR testing (4.45 × 109/l; SD = 2.35; p = 0.91). A total of 10 patients (9.5%) had neutropenia. The age, dose of clozapine and duration of treatment were not statistically different compared to the group without neutropenia.

CONCLUSION

Psychiatrists and other health professionals should keep in mind that neutrophil count may decrease during COVID-19 infection in patients taking clozapine and in some cases, neutropenia may even occur. We assumed that neutropenia could be caused by COVID-19 and clozapine interaction.

The association between vitamin D and symptom domains in psychotic disorders: A systematic review

BACKGROUND

Vitamin D deficiency is prevalent among people with psychosis and may play a role in the aetiology of psychotic disorders. However, its impact on clinical symptom severity has not been independently reviewed.

METHODS

We conducted a systematic search of randomized trials and observational studies that assessed the relationship between vitamin D and symptom domains (positive and negative psychotic symptoms, total and general psychopathology, cognitive and depressive) in people with a psychotic disorder.

RESULTS

1040 articles were identified, of which 29 were eligible for inclusion: 26 observational studies and 3 randomized trials. Five studies included people with First-Episode Psychosis (FEP) and 24 included people with enduring psychosis. Most observational studies found that vitamin D was inversely associated with negative symptoms (57%; 13/23), positively associated with cognitive performance (63%; 5/8), and bore no association with positive symptoms (68%; 15/22), total psychopathology (64%; 7/11), general psychopathology (57%; 4/7) or depressive symptoms (64%; 9/14). Randomized controlled trials indicated that vitamin D supplementation improved cognitive performance (100%; 1/1) and, in some cases, reduced total psychopathology (50%; 1/2), general psychopathology (50%; 1/2) and negative symptoms (30%; 1/3), but had no effect on positive (100%; 3/3) or depressive (100%; 3/3) symptoms. Some positive associations were attenuated when controlled for potential confounders.

CONCLUSION

Low vitamin D was found to be inversely associated with more severe clinical symptoms in some, but not all symptom domains in people with psychosis. These preliminary findings warrant further exploration, particularly in regard to cognitive performance and negative symptoms.

Serum vitamin D levels in relation to metabolic syndrome: A systematic review and dose-response meta-analysis of epidemiologic studies

Several epidemiological studies examined the association of serum vitamin D with metabolic syndrome (MetS), but the findings were inconsistent. We conducted a systematic review and dose-response meta-analysis to quantify the association between blood vitamin D levels and MetS in adults. A systematic search up to December 2020 was conducted in MEDLINE (PubMed), ISI (Web of Science), Scopus, and Google Scholar databases for epidemiological studies that assessed the relation of serum 25-hydroxyvitamin D (as the exposure) and MetS (as the outcome) in adults. Eligible cross-sectional studies were restricted to those with representative populations. Finally, 43 studies were included in the analysis (38 cross-sectional, one nested case-control, and four cohorts studies). Combining 41 effect sizes from 38 cross-sectional studies included 298,187 general adult population revealed that the highest level of serum vitamin D, compared with the lowest level, was significantly related to a 43% decreased odds of MetS in developed countries (odds ratio [OR]: 0.57; 95% confidence interval [CI]: 0.49-0.65) and 40% in developing countries (OR: 0.60; 95% CI: 0.52-0.70). Linear dose-response analysis (including 222,175 healthy individuals and 39,308 MetS patients) revealed that each 25 nmol/L increase in serum vitamin D level was significantly associated with a 15% decreased odds of MetS (OR: 0.85; 95% CI: 0.80-0.91); however, we found no significant nonlinear association. Meta-analysis of five prospective studies with 11,019 participants revealed no significant relation (relative risk [RR]: 0.70; 95% CI: 0.37-1.32). This meta-analysis indicated an inverse association between serum vitamin D concentrations and risk of MetS in general adult populations in cross-sectional studies in a dose-response manner. However, no significant association was found in a small number of cohorts. More prospective studies are needed to confirm the causality of this relationship.

Maternal Vitamin D and its Role in Determining Fetal Origins of Mental Health

There is evidence that mental health disorders may have roots in fetal life and are associated with deficiencies in various micronutrients, including vitamin D. During pregnancy, vitamin D balance is influenced by an increase in maternal calcitriol and a substantial increase in maternal Vitamin D Binding Protein concentrations. In the early stages of life, vitamin D is necessary to mediate numerous brain processes such as proliferation, apoptosis, and neurotransmission. Furthermore, Vitamin D has a recognized anti-inflammatory activity that normally suppresses inflammation. Increased activation of hypothalamo-pituitary-adrenal axis (HPA) and inflammation during gestation may influence maternal health and fetal neurodevelopment during and beyond pregnancy. A deficit of Vitamin D and maternal stressful events during gestation, such as perinatal depression, could influence the efficacy of the immune system altering its activity. Vitamin D deficiency during gestation associated with a reduction in fetal brain development has been widely described and correlated with alteration in the production of the brain-derived neurotrophic factor. To this regard, many studies highlights that low maternal vitamin D dosage during gestation has been related to a significantly greater risk to develop schizophrenia and other severe mental illnesses in later life. The objective of this paper is a comprehensive overview of maternal vitamin D balance in determining the fetal origins of mental health with some references to the link between vitamin D levels, inflammatory responses to stress and mental disorders in adult life.

Vitamin D deficiency in long-term hospitalization psychiatric wards in an equatorial nation

INTRODUCTION

Vitamin D deficiency and insufficiency have been shown to be prevalent in several populations, including in people who have a mental illness. Deficiency has been linked to specific mental health sequelae. Furthermore, deficiency may be perpetuated by medications routinely prescribed to people with severe mental illness. Therefore, symptoms of mental illness may be exacerbated by deficient levels of vitamin D, and treatments for mental illness may exacerbate deficiency. This study sought to determine the vitamin D levels of people hospitalized for a period longer than a year in an equatorial nation, Singapore. The inpatient population was then categorized according to levels to determine the need for supplementation.

METHODS

Total 25-hydroxy vitamin D in serum and plasma levels were tested in 403 individuals in long-term psychiatric wards. Blood serum and plasma levels were classified into three groups. Regression models were constructed to test the associations between levels and clinical covariates.

RESULTS

Forty (9.9%) people had vitamin D levels that were sufficient. A link was found between vitamin D levels and medications given for gastrointestinal illnesses (β -2.48, p = .014, 95%CI -4.46 to-0.51) and between vitamin D levels and length of stay (β -0.13, p = .027, 95%CI -0.24 to-0.01). No other relationships were statistically significant.

DISCUSSION

Despite its geographic location and opportunities for regular outdoor activity, vitamin D deficiency, and insufficiency are prevalent among people hospitalized for long periods of time in an equatorial nation. The level of deficiency is comparable to those observed in other settings.

Vitamin D deficiency in schizophrenia implications for COVID-19 infection

Vitamin D deficiency is associated with an increased risk of acute respiratory infection. There is an excess of respiratory infections and deaths in schizophrenia, a condition where vitamin D deficiency is especially prevalent. This potentially offers a modifiable risk factor to reduce the risk for and the severity of respiratory infection in people with schizophrenia, although there is as yet no evidence regarding the risk of COVID-19. In this narrative review, we describe the prevalence of vitamin D deficiency in schizophrenia, report the research examining the relationship between vitamin D levels and COVID-19 and discuss the associations between vitamin D deficiency and respiratory infection, including its immunomodulatory mechanism of action.

Vitamin D concentration and psychotic disorder: associations with disease status, clinical variables and urbanicity

BACKGROUND

The association between schizophrenia and decreased vitamin D levels is well documented. Low maternal and postnatal vitamin D levels suggest a possible etiological mechanism. Alternatively, vitamin D deficiency in patients with schizophrenia is presumably (also) the result of disease-related factors or demographic risk factors such as urbanicity.

METHODS

In a study population of 347 patients with psychotic disorder and 282 controls, group differences in vitamin D concentration were examined. Within the patient group, associations between vitamin D, symptom levels and clinical variables were analyzed. Group × urbanicity interactions in the model of vitamin D concentration were examined. Both current urbanicity and urbanicity at birth were assessed.

RESULTS

Vitamin D concentrations were significantly lower in patients (B = -8.05; 95% confidence interval (CI) -13.68 to -2.42; p = 0.005). In patients, higher vitamin D concentration was associated with lower positive (B = -0.02; 95% CI -0.04 to 0.00; p = 0.049) and negative symptom levels (B = -0.03; 95% CI -0.05 to -0.01; p = 0.008). Group differences were moderated by urbanicity at birth (χ2 = 6.76 and p = 0.001), but not by current urbanicity (χ2 = 1.50 and p = 0.224). Urbanicity at birth was negatively associated with vitamin D concentration in patients (B = -5.11; 95% CI -9.41 to -0.81; p = 0.020), but not in controls (B = 0.72; 95% CI -4.02 to 5.46; p = 0.765).

CONCLUSIONS

Lower vitamin D levels in patients with psychotic disorder may in part reflect the effect of psychosis risk mediated by early environmental adversity. The data also suggest that lower vitamin D and psychopathology may be related through direct or indirect mechanisms.

Vitamin D deficiency and Schizophrenia in Adults: A Systematic Review and Meta-analysis of Observational Studies

Schizophrenia is a heterogeneous disorder in which there is an interaction between genetic and environmental factors. Accumulating data show that there may be an association between vitamin D deficiency and schizophrenia. We conducted an updated meta-analysis to investigate the relationship between schizophrenia and blood vitamin D level. All published observational articles have been searched from five databases until September 2019. In total, 36 articles with a total of 12528 participants were included in this study. Patients with schizophrenia have significantly lower levels of vitamin D than controls. The subgroup analyses based on study design, hospitalization status, quality score, type of biomarker [25-hydroxyvitamin D or 25-hydroxyvitamin D₃], and the country did not explain between-study heterogeneity; however, meta-regression on match factors indicted that match of BMI could account for some degree of heterogeneity. No significant differences in publication bias were observed. Also, subjects with schizophrenia were more likely to have vitamin D deficiency or insufficiency compared to controls. In conclusion, our analyses are consistent with the hypothesis that vitamin D deficiency is associated with schizophrenia. More well-designed randomized control trials are needed to determine whether this association is causal.

Vitamin D supplementation compared to placebo in people with First Episode psychosis - Neuroprotection Design (DFEND): a protocol for a randomised, double-blind, placebo-controlled, parallel-group trial

Background

People experiencing their first episode of psychosis are often deficient in vitamin D. Observational studies have reported an association between low vitamin D concentrations and poorer subsequent health outcomes in psychosis. A vitamin D deficiency in neonates and children has been linked to a later increased risk of schizophrenia and psychotic-like experiences. This trial aims to examine the effect of high-dose vitamin D supplementation on outcomes in early psychosis. We hypothesise that vitamin D supplementation will be associated with better mental health outcomes.

Methods/design

The DFEND study is a multicentre double-blind placebo-controlled parallel-group trial of vitamin D supplementation in people with early psychosis. Patients with an ICD-10 diagnosis of functional psychosis will be randomised in a 1:1 ratio to receive either 120,000 IU/month of vitamin D (cholecalciferol) or a matched placebo for 6 months. The primary outcome is the total Positive and Negative Syndrome Scale (PANSS) score at the 6-month follow-up for all patients. Secondary outcomes include assessment of mood (Calgary Depression Scale), general function (Global Assessment of Functioning), cardiovascular risk (body mass index, waist circumference, C-reactive protein, cholesterol and HbA1c) and vitamin D levels at the 6-month follow-up. Additionally, 3- and 6-month total PANSS scores will be analysed for those with inadequate vitamin D levels at the baseline.

Discussion

The DFEND study is the first trial to examine whether vitamin D supplementation in early psychosis is associated with better mental health outcomes. The findings of this study may help to resolve the clinical equipoise regarding the benefits and cost-effectiveness of routine vitamin D supplementation in people with psychosis.

Trial registration

ISRCTN, ISRCTN12424842. Registered on 25 February 2015.

Pathogenesis and management of Brugada syndrome in schizophrenia: A scoping review

CONTEXT

Excess cardiovascular morbidity and an increased prevalence of sudden cardiac death (SCD) contributes to premature mortality in schizophrenia. Brugada syndrome (BrS) is an important but underrecognized cause of SCD. It is more commonly seen in schizophrenia than in general population controls.

METHODS

We conducted a scoping review to describe the pathogenesis of BrS in schizophrenia and to identify the psychotropic medications that increase the risk of unmasking BrS and associated ventricular arrhythmias resulting in SCD.

FINDINGS

Schizophrenia and BrS share similar calcium channel abnormalities, which may result in aberrant myocardial conductivity. It remains uncertain if there is a genetic pre-disposition for BrS in a subset of patients with schizophrenia. However, the unmasking of Brugada ECG patterns with the use of certain antipsychotics and antidepressants increases the risk of precipitating SCD, independent of QT prolongation.

CONCLUSIONS AND FUTURE DIRECTIONS

Specific cardiology assessment and interventions may be required for the congenital or unmasked Brugada ECG pattern in schizophrenia. The current long-term standard of care for BrS is an implantable cardioverter defibrillator (ICD), but post-implantation psychological effects must be considered. Careful use of antipsychotic and other psychotropic medications is necessary to minimize proarrhythmic effects due to impact on cardiac sodium and calcium ion channels. When prescribing such drugs to patients with schizophrenia, clinicians should be mindful of the potentially fatal unmasking of Brugada ECG patterns and how to manage it. We present recommendations for psychiatrists managing this patient population.

Management of clozapine treatment during the COVID-19 pandemic

Clozapine is the only available treatment for refractory schizophrenia but its use involves frequent physical contact with healthcare workers for the purpose of mandatory blood monitoring. During the COVID-19 pandemic, patients taking clozapine will be self-isolating to reduce the risk of infection, not least because these patients are at high risk of serious illness and fatality because of high rates of diabetes, obesity and pulmonary disease and an increased risk of pneumonia. Problems may also arise because both clozapine-induced myocarditis and neutropenic sepsis share signs and symptoms with COVID-19 (fever, chest pain, dyspnoea, etc.). We recommend decreasing the frequency of physical contacts by extending the blood monitoring interval to 12 weeks in those patients taking clozapine for more than 1 year. To distinguish COVID-19 from clozapine-related physical adverse effects, we suggest an urgent antigen test alongside a full blood count. In those taking clozapine who develop COVID-19, we suggest continuing with clozapine whenever possible (even during ventilation), reducing the dose if necessary in line with blood assay results. Blood monitoring should continue but clozapine should only cease if there is a significant fall in neutrophils (COVID-19 is linked to lymphopenia but not neutropenia). To protect against the likelihood and severity of respiratory infection, we recommend the use of vitamin D in all clozapine patients. Initiation of clozapine is likely to remain problematic while the risk of infection remains, given the degree of physical contact required to assure safety.

Serum Prolactin and Bone Mineral Density in Schizophrenia: A Systematic Review

The relationship between serum prolactin and bone mineral density (BMD) in schizophrenia is unclear. We conducted a literature review of databases from inception until December 2018 for cross-sectional, case-control, prospective and retrospective studies analyzing correlations between serum prolactin and BMD measured using dual energy X-ray absorptiometry or quantitative ultrasound at any skeletal site in people with schizophrenia. Data was summarized with a best evidence synthesis. This review identified 15 studies (1 longitudinal study, 10 cross-sectional and 4 case-control studies; 1,360 individuals with a psychotic disorder; mean age 45.1 ± 9.4 [standard deviation] years, female 742 [54.6%], mean illness duration 17.7 ± 11.3 years) assessing the relationship between serum prolactin and BMD in schizophrenia. There was a statistically significant inverse correlation between serum prolactin and BMD identified in eight of the studies (53% of all studies), suggesting mixed evidence for an association between serum prolactin and BMD. Of those studies which identified a significant inverse correlation between serum prolactin and BMD (n = 5), 152 (52.1%) of patients were treated with prolactin raising antipsychotics, compared to 197 (48.1%) of patients in those studies which did not identify a significant correlation between prolactin and BMD. Available studies cannot resolve the link between excess prolactin and reduced BMD in schizophrenia. Future studies should be longitudinal in design and combine measures of serum prolactin along with other risk factors for reduced BMD such as smoking and vitamin D and sex hormone levels in assessing the relationship between prolactin and BMD in schizophrenia.

Vitamin D in schizophrenia and depression: a clinical review

Evidence from preclinical and clinical studies supports a role for vitamin D deficiency in many mental disorders. In this review, we discuss the role of vitamin D in the aetiology and treatment of schizophrenia and depression and their physical health comorbidities. Although observational studies support a potential association between vitamin D and schizophrenia and depression, sufficient high-quality evidence from clinical trials does not yet exist to establish a place for vitamin D supplementation in optimising clinical response or promoting physical health. Completed randomised controlled trials are needed to provide insights into the efficacy and safety of vitamin D in the management of mental disorders.

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DECLARATION OF INTEREST

F.G. has received support or honoraria for CME, advisory work and lectures from Bristol-Myers Squibb, Janssen, Lundbeck, Otsuka, Roche and Sunovion, and has a family member with professional links to Lilly and GSK, including shares. She is in part funded by the National Institute for Health Research's (NIHR) Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London and the South London Collaboration for Leadership in Applied Health Research & Care Funding scheme, and by the Maudsley Charity. The views expressed in this article are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Vitamin D deficiency in a psychiatric population and correlation between vitamin D and CRP

OBJECTIVES

The main objective of the study was to assess 25-hydroxyvitamin D (25(OH)D) status in a psychiatric population in France according to psychiatric diagnoses. The secondary objective was to investigate a correlation between 25(OH)D and CRP.

METHODS

A retrospective study from February 1st, 2014 to January 31, 2016, was carried out in a French psychiatric hospital. Inpatients with a 25(OH)D measure were included. Variables including ethnic origin, BMI, psychiatric diagnoses, medical history and CRP were collected. Factors associated with 25(OH)D and CRP were studied in univariate and multivariate analyses, as was the correlation between 25(OH)D and CRP.

RESULTS

Among 604 patients included, 80.6% presented 25(OH)D deficiency of which 46.9% with 25(OH)D<50nmol/L. 25(OH)D varied with age, ethnic origin, BMI, season, CRP and medical history. It was associated with schizophrenia in univariate analysis but not in multivariate analyses considering age and BMI. CRP varied with age, BMI and medical conditions but not with psychiatric diagnoses. 25(OH)D was inversely correlated with CRP.

CONCLUSION

This psychiatric population was significantly more deficient in 25(OH)D than the French population in general. 25(OH)D was inversely correlated with CRP as observed in the general population.

Vitamin D in Synaptic Plasticity, Cognitive Function, and Neuropsychiatric Illness

Over a billion people worldwide are affected by vitamin D deficiency. Although vitamin D deficiency is associated with impaired cognition, the mechanisms mediating this link are poorly understood. The extracellular matrix (ECM) has now emerged as an important participant of synaptic plasticity and a new hypothesis is that vitamin D may interact with aggregates of the ECM, perineuronal nets (PNNs), to regulate brain plasticity. Dysregulation of PNNs caused by vitamin D deficiency may contribute to the presentation of cognitive deficits. Understanding the molecular mechanisms underpinning the role of vitamin D in brain plasticity and cognition could help identify ways to treat cognitive symptoms in schizophrenia and other neuropsychiatric conditions.

Vitamin D and clinical symptoms in First Episode Psychosis (FEP): A prospective cohort study

BACKGROUND

There is a paucity of longitudinal research investigating vitamin D in people with early psychosis.

METHOD

Vitamin D levels were measured in 168 patients (64% (n = 108) male, mean age 29.3 (9.8) years) with first episode psychosis (FEP), along with measures of clinical state at baseline and at 12 months follow up. We assessed the a) cross sectional, and; b) longitudinal relationships between continuous and categorical 25-hydroxyvitamin D (25(OH)D) levels and clinical symptoms at first contact for psychosis and at 12 months.

RESULTS

In FEP, 80% (n = 134) at baseline, and 76% at 12 months follow up, had suboptimal vitamin D levels (<20 ng/ml). Suboptimal levels of 25 (OH) D at baseline were not cross-sectionally associated with clinical symptoms. Higher vitamin D levels at baseline (n = 77) were significantly associated with better visual reproduction-immediate recall (β = 0.249, 95%CI = -0.012-0.871, p = 0.044). Higher baseline vitamin D levels were prospectively associated with lower total PANSS (β = -0.24, 95%CI = -0.47-0.01, p = 0.04) and PANSS negative symptom scores (β = -0.12, 95%CI = -0.23-0.01, p = 0.04) at 12 months.

CONCLUSION

We identified a prospective association between higher baseline serum Vitamin D levels and lower total psychotic symptoms and negative symptoms of psychosis at 12 months after first contact for psychosis. The results of this study require replication in larger prospective studies, and highlight the need for large randomised trials to assess the effect of vitamin D supplementation on symptoms of psychosis in FEP.

Predictors of falls and fractures leading to hospitalization in people with schizophrenia spectrum disorder: A large representative cohort study

AIM

To investigate predictors of falls/fractures leading to hospitalisation in people with schizophrenia-spectrum disorders.

METHODS

A historical cohort of people with schizophrenia-spectrum disorders (ICD F20-29) from 01/2006-12/2012 was assembled using data from the South London and Maudsley NHS Biomedical Research Centre Case Register. Falls/fractures were ascertained from a linkage to national hospitalisation data. Separate multivariate Cox regression analyses were employed to identify predictors of falls and fractures.

RESULTS

Of 11,567 people with schizophrenia-spectrum disorders (mean age 42.6 years, 43% female), 579 (incidence rate 12.79 per 1000 person-years) and 528 (11.65 per 1000 person-years) had at least one reported hospital admission due to a fall or fracture respectively and 822 patients had at least either a recorded fall or a fracture during this period (i.e. 7.1% of sample). Overall, 6.69 and 10.74 years of inpatient hospital stay per 1000-person years of follow-up occurred due to a fall and fracture respectively. 14(0.12%) and 28(0.24%) died due to a fall and fracture respectively. In Multivariable analysis, increasing age, white ethnicity, analgesics, cardiovascular disease, hypertension, diseases of the genitourinary system, visual disturbance and syncope were significant risk factor for both falls and fractures. A previous fracture (HR 2.05, 95% CI 1.53-2.73) and osteoporosis (HR 6.79, 95% CI 4.71-9.78) were strong risk factors for consequent fractures.

CONCLUSION

Comorbid physical health conditions and analgesic medication prescription were associated with higher risk of falls and fractures. Osteoporosis and previous fracture were strong predictors for subsequent fractures. Interventions targeting bone health and falls/fractures need to be developed and evaluated in these populations.

Nutritional Deficiencies and Clinical Correlates in First-Episode Psychosis: A Systematic Review and Meta-analysis

Objective

Diet is increasingly recognized as a potentially modifiable factor influencing the onset and outcomes of psychiatric disorders. Whereas, previous research has shown long-term schizophrenia is associated with various nutritional deficiencies, this meta-analysis aimed to determine the prevalence and extent of nutritional deficits in first-episode psychosis (FEP).

Method

A search of electronic databases conducted in July 2017 identified 28 eligible studies, examining blood levels of 6 vitamins and 10 minerals across 2612 individuals: 1221 individuals with FEP and 1391 control subjects. Meta-analyses compared nutrient levels in FEP to nonpsychiatric controls. Clinical correlates of nutritional status in patient samples were systematically reviewed.

Results

Significantly lower blood levels of folate (N = 6, n = 827, g = -0.624, 95% confidence interval [CI] = -1.176 to -0.072, P = .027) and vitamin D (N = 7, n = 906, g = -1.055, 95% CI = -1.99 to -0.119, P = .027) were found in FEP compared to healthy controls. Synthesis of clinical correlates found both folate and vitamin D held significant inverse relationships with psychiatric symptoms in FEP. There was also limited evidence for serum level reductions of vitamin C (N = 2, n = 96, g = -2.207, 95% CI = -3.71 to -0.71, P = .004). No differences were found for other vitamins or minerals.

Conclusions

Deficits in vitamin D and folate previously observed in long-term schizophrenia appear to exist from illness onset, and are associated with worse symptomology. Further research must examine the direction and nature of these relationships (ie, mediator, moderator, or marker) with clinical status in FEP. Future trials assessing efficacy of nutrient supplementation in FEP samples should consider targeting and stratifying for baseline deficiency.

Prevalence, risk factors and clinical characteristics of osteoporosis in Chinese inpatients with schizophrenia

Patients with schizophrenia have a high prevalence of developing osteoporosis and osteoporosis-related fractures. We examined the prevalence of osteoporosis and its clinical correlates in Chinese patients with schizophrenia, which is not well-studied. A total of 199 inpatients (males/females=132/67; average age: 54.5±11.1years) and 107 healthy controls (males/females=22/85; average age: 41.7±11.9years) were recruited. Bone mineral density (BMD) was measured by ultrasonography of the calcaneus. The prevalence of osteoporosis and low BMD (osteoporosis and osteopenia) was 23.1% and 65.3% for the patient group, versus 7.5% and 39.3% for the control group (both p<0.001). Further, the average BMD T-score in patients was significantly lower than in controls (p<0.05). There was gender difference in the prevalence of low BMD conditions for the patients (males: 56.1% versus females: 76.1%; p<0.01) as well as the BMD T-score (p<0.001). Several risk factors correlated with the osteoporosis classification in the patient group: older age (58.9±11.2years vs. 53.3±11.0years), lower weight (63.7±12.2kg vs. 70.4±15.2kg) and body mass index (BMI) (22.8±4.1kg/m² vs. 24.2±4.7kg/m²; all p<0.01) than those without osteoporosis. Stepwise multiple logistic regression analysis indicated that age, weight and BMI remained significantly associated with osteoporosis. In addition, correlation analysis showed significant correlations between BMD T-score and the following parameters: gender, age and drug type (clozapine versus non-clozapine) (Bonferroni corrected p's<0.05). Our results suggest a higher prevalence of osteoporosis and osteopenia in Chinese schizophrenic inpatients, with both the expected risk factors of gender and age, as well as drug type.

Association of Serum Level of 25-Hydroxy Vitamin D Deficiency and Pulmonary Function in Healthy Individuals

Background

Besides the extensive regulatory role in growing number of biologic processes, vitamin D has been recently considered essential for lungs function as well as protective against exacerbation of chronic obstructive pulmonary diseases. We assessed the correlation between vitamin D serum levels with pulmonary function in healthy individuals.

Methods

In a cross-sectional study, healthy volunteer (n = 92) participants underwent the following laboratory procedures: a blood test, a 24-hour urine collection test, and the serum level of 25-hydroxy vitamin D before undergoing spirometry. Linear correlation coefficient was calculated to detect the association between serum level of 25-hydroxy vitamin D and pulmonary volumes.

Results

The mean age of participants was 39.95 ± 9.98 years. 48% of participants showed different levels of 25-hydroxy vitamin D deficiency. We recognized a consistent direct positive correlation between serum levels of 25-hydroxy vitamin D and lung function volumes. The coefficient for forced vital capacity, forced expiratory volume in 1 second, forced expiratory flow 25–75%, and forced expiratory volume in 1 second/forced vital capacity ratio were 0.610, 0.509, 0.454, and 0.551, respectively.

Conclusions

Our findings suggest correlation between higher serum levels of 25-hydroxy vitamin D and improved pulmonary function. Accordingly, supplemental vitamin D might significantly improve treatment response.

C-Reactive Protein as a Peripheral Biomarker in Schizophrenia. An Updated Systematic Review

Objectives: The objective of this systematic review was to synthetize the published data on the relationships between elevated blood C-reactive protein (CRP) levels and schizophrenia (SZ) onset risk, illness characteristics and treatments, cognition and physical health. Method: The systematic bibliographic searches have been carried out according to the Cochrane methodology. Medline, web of science, Google Scholar with each database being searched from inception to November 2017. Results: 53 studies were included in the present review. While meta-analyses including case-control studies suggest a clear association between CRP and SZ, one other study has suggested that CRP-associated genes were associated with a lower risk of SZ onset. Increased CRP has been significantly associated with positive symptoms in acute phase psychosis, while studies including community-dwelling stabilized subjects did not find such an association. Abnormal CRP has been associated with a wide range of cognitive impairment in SZ stabilized individuals. Body Mass index has been extensively associated with increased CRP in SZ subjects; and increased CRP has been identified as a risk factor for metabolic syndrome and cardiovascular risk in SZ subjects. Increased CRP has also been associated with high nicotine dependence in SZ smokers and one study has suggested that increased CRP was associated with sedentary behavior. Conclusion: In the light of the above-mentioned studies, increased hs-CRP may be reasonably suggested as a marker for SZ onset risk, as well as a risk factor for increased positive symptoms, cognitive impairment, hypovitaminosis D, microbiota disturbances, cardiovascular and metabolic syndrome risk in SZ subjects, and increased nicotine dependence in SZ smokers. In case of increased CRP levels, anti-inflammatory strategies (add-on anti-inflammatory drugs including aspirin and omega 3 fatty acids, vitamin D supplementation, physical activity, probiotics) should be also further evaluated. Limits: Most of the studies were cross-sectional and cohort studies are needed to determine the temporal relationship between increased CRP and the psychiatric outcomes.

Vitamin D Supplementation in Chronic Schizophrenia Patients Treated with Clozapine: A Randomized, Double-Blind, Placebo-controlled Clinical Trial

BACKGROUND

While accumulating evidence suggests that vitamin D deficiency may be involved in the risk to develop schizophrenia and its outcome, there are no studies on vitamin D supplementation in this context. We sought to assess the effect of vitamin D supplementation on psychiatric, cognitive and metabolic parameters in chronic clozapine-treated schizophrenia patients.

METHODS

This eight-week, randomized, double-blind, placebo-controlled clinical trial, recruited schizophrenia patients who had been maintained on clozapine treatment for at least 18weeks and had low levels of vitamin D (<75nmol/l) and total PANSS scores >70 (to ascertain the presence of residual symptoms). Patients were randomly allocated to either weekly oral drops of vitamin D (14,000IU) or placebo and subsequently assessed at two-week intervals for psychosis severity, mood, cognition and metabolic profile.

RESULTS

Twenty four patients were randomly assigned to vitamin D (aged 39.4±9.6years, 75% males) and the other 23 patients to the placebo arm (aged 42.5±11.2years, 60.9% males). After eight weeks, the vitamin D group exhibited a significant increase in vitamin D levels (31.4 vs -0.4nmol/l, p<0.0001). There was no significant effect of vitamin D on psychotic, depressive or metabolic parameters. However, in the vitamin D group, there was a trend towards improved cognition (effect size=0.17, significance lost following Bonferroni correction).

CONCLUSIONS

Vitamin D supplementation was associated with a trend towards improved cognition, but did not affect psychosis, mood or metabolic status. It is possible that the robust decrease in the PANSS scores in both groups may have obscured an effect of vitamin D supplementation.

Hyperprolactinaemia in first episode psychosis - A longitudinal assessment

Little is known about hyperprolactinaemia (HPL) in first episode psychosis (FEP) patients. We investigated longitudinal changes in serum prolactin in FEP, and the relationship between HPL, and antipsychotic medication and stress. Serum prolactin was recorded in FEP patients at recruitment and again, 3 and 12months later. HPL was defined as a serum prolactin level >410mIU/L (~19.3ng/ml) for males, and a serum prolactin level >510mIU/L (~24.1ng/ml) for females. From a total of 174 people with serum prolactin measurements at study recruitment, 43% (n=74) had HPL, whilst 27% (n=21/78) and 27% (n=26/95) had HPL at 3 and 12months respectively. We observed higher serum prolactin levels in females versus males (p<0.001), and in antipsychotic treated (n=68) versus antipsychotic naïve patients (p<0.0001). Prolactin levels were consistently raised in FEP patients taking risperidone, amisulpride and FGAs compared to other antipsychotics. No significant relationship was observed between perceived stress scores (β=7.13, t=0.21, df=11, p=0.0.84 95% CI -72.91-87.16), or objective life stressors (β=-21.74, t=-0.31, df=8, p=0.77 95% CI -218.57-175.09) and serum prolactin. Our study found elevated rates of HPL over the course of the first 12months of illness. We found no evidence to support the notion that stress is related to elevated serum prolactin at the onset of psychosis.

Prevalence and correlates of suboptimal vitamin D status in people living with psychotic disorders: Data from the Australian Survey of High Impact Psychosis

OBJECTIVE

Having sufficient sera concentrations of 25-hydroxyvitamin D is important for a range of health outcomes including cardiometabolic diseases. Clinical studies in people with psychotic disorders suggest that a sizable proportion has suboptimal vitamin D status (i.e. vitamin D deficiency or insufficiency). Individuals with psychosis also have many of the risk factors associated with suboptimal vitamin D status such as smoking, obesity, and reduced physical activity. The aim of this study was to examine the prevalence and socio-demographic and clinical correlates of vitamin D status using a large, population-based sample of adults with psychotic disorders.

METHODS

Data were collected as part of the Survey of High Impact Psychosis, a population-based survey of Australians aged 18-64 years with a psychotic disorder. 25-Hydroxyvitamin D concentration was measured in 463 participants. 25-Hydroxyvitamin D concentration was dichotomised into optimal (above 50 nmol/L) and suboptimal (below 50 nmol/L). The influence of a range of socio-demographic and clinical variables on vitamin D status was examined using logistic regression.

RESULTS

Nearly half (43.6%) of the participants had suboptimal vitamin D status. Those with (a) increased physical activity or (b) positive symptoms had significantly reduced odds of having suboptimal vitamin D status. However, there were no significant associations between suboptimal vitamin D status and other psychiatric symptom measures or cardiometabolic risk factors.

CONCLUSION

Many people with psychotic disorders have suboptimal vitamin D status. As part of the routine assessment of physical health status, clinicians should remain mindful of vitamin D status in this vulnerable population and encourage the use of appropriate vitamin D supplements.

The effects of vitamin and mineral supplementation on symptoms of schizophrenia: a systematic review and meta-analysis

BACKGROUND

When used as an adjunctive with antipsychotics, certain vitamins and minerals may be effective for improving symptomatic outcomes of schizophrenia, by restoring nutritional deficits, reducing oxidative stress, or modulating neurological pathways.

METHOD

We conducted a systematic review of all randomized controlled trials (RCTs) reporting effects of vitamin and/or mineral supplements on psychiatric symptoms in people with schizophrenia. Random-effects meta-analyses were used to calculate the standardized mean difference between nutrient and placebo treatments.

RESULTS

An electronic database search in July 2016 identified 18 eligible RCTs, with outcome data for 832 patients. Pooled effects showed that vitamin B supplementation (including B6, B8 and B12) reduced psychiatric symptoms significantly more than control conditions [g = 0.508, 95% confidence interval (CI) 0.01-1.01, p = 0.047, I 2 = 72.3%]. Similar effects were observed among vitamin B RCTs which used intention-to-treat analyses (g = 0.734, 95% CI 0.00-1.49, p = 0.051). However, no effects of B vitamins were observed in individual domains of positive and negative symptoms (both p > 0.1). Meta-regression analyses showed that shorter illness duration was associated with greater vitamin B effectiveness (p = 0.001). There were no overall effects from antioxidant vitamins, inositol or dietary minerals on psychiatric symptoms.

CONCLUSIONS

There is preliminary evidence that certain vitamin and mineral supplements may reduce psychiatric symptoms in some people with schizophrenia. Further research is needed to examine how the benefits of supplementation relate to nutrient deficits and the impact upon underlying neurobiological pathways, in order to establish optimal nutrient formulations for improving clinical outcomes in this population. Future studies should also explore the effects of combining beneficial nutrients within multi-nutrient formulas.

Correlates of vitamin D in psychotic disorders: A comprehensive systematic review

People with psychosis have high prevalence of low vitamin D levels but the correlates and relevance of this deficiency are unclear. A systematic search of major databases from inception to 03/2016 was undertaken investigating correlates of vitamin D in people with psychosis. Data was summarised with a best evidence synthesis. Across 23 included studies (n=1770 psychosis, n=8171 controls) a mean difference in vitamin D levels between both groups of -11.14ng/ml±0.59 was found. 53 unique correlations between vitamin D and outcomes in people with psychosis were identified. The evidence base was broadly equivocal although season of blood sampling (67% of studies found a positive correlation with warmer seasons) and parathyroid hormone (100% of studies found a negative correlation) were associated with vitamin D levels. The most commonly non-correlated variables were: BMI (83% found no correlation), age (73%), gender (86%), smoking (100%), duration of illness (100%) and general assessment of functioning score (100%). In conclusion, whilst many unique correlates have been investigated, there is weak and inconclusive evidence regarding the consistency and meaning of the correlates of vitamin D levels in people with psychosis. Future longitudinal studies should consider the correlates of vitamin D in people with psychosis.

Cardiovascular diseases, depression disorders and potential effects of omega-3 fatty acids

Cardiovascular disease (CVD) and depressive disorders (DD) are two of the most prevalent health problems in the world. Although CVD and depression have different origin, they share some common pathophysiological characteristics and risk factors, such as the increased production of proinflammatory cytokines, endothelial dysfunction, blood flow abnormalities, decreased glucose metabolism, elevated plasma homocysteine levels, oxidative stress and disorder in vitamin D metabolism. Current findings confirm the common underlying factors for both pathologies, which are related to dramatic dietary changes in the mid-19th century. By changing dietary ratio of omega-6 to omega-3 fatty acids from 1:1 to 15-20:1 some changes in metabolism were induced, such as increased pro-inflammatory mediators and modulations of different signaling pathways following pathophysiological response related to both, cardiovascular diseases and depressive disorders.

Vitamin-D Deficiency As a Potential Environmental Risk Factor in Multiple Sclerosis, Schizophrenia, and Autism

In this short review, we want to summarize the current findings on the role of vitamin-D in multiple sclerosis (MS), schizophrenia, and autism. Many studies have highlighted hypovitaminosis-D as a potential environmental risk factor for a variety of conditions such as MS, asthma, cardiovascular disease, and, more recently, psychiatric diseases. However, whether hypovitaminosis-D is a potential causative factor for the development or activity in these conditions or whether hypovitaminosis-D may be due to increased vitamin-D consumption by an activated immune system (reverse causation) is the focus of intense research. Here, we will discuss current evidence exploring the role of vitamin-D in MS, schizophrenia, and autism and its impact on adaptive and innate immunity, antimicrobial defense, the microbiome, neuroinflammation, behavior, and neurogenesis. More work is needed to gain insight into its role in the underlying pathophysiology of these conditions as it may offer attractive means of intervention and prevention.

Lower Bone Mineral Density at the Hip and Lumbar Spine in People with Psychosis Versus Controls: a Comprehensive Review and Skeletal Site-Specific Meta-analysis

It remains unclear if differences in bone mineral density (BMD) exist at different skeletal sites between people with schizophrenia and age- and sex-matched healthy controls (HCs). Major databases were searched from inception until February 2016 for studies measuring BMD using dual-energy X-ray absorptiometry (DXA) at any skeletal site in individuals with schizophrenia. Ten studies investigating 827 people with schizophrenia (55.4 % female, 33.8 ± 9.7 years) and 1379 HCs (58.7 % female, 34.7 ± 9.1 years) were included. People with schizophrenia had significantly reduced BMD at the lumbar spine (standardised mean difference adjusted for publication bias (SMD) = -0.950 (95 % CI = -1.23 to -0.66, fail-safe number = 825) and hip (SMD = -0.534, 95 % CI = -0.876 to -0.192, fail-safe number = 186). A higher proportion of hyperprolactinaemia (β = -0.0102, p < 0.0001) and smokers (β = -0.0099, p = 0.02) moderated a larger reduced BMD at the lumbar spine. Further research is required to investigate if low bone mass and fractures can be prevented in people with schizophrenia.

Vitamin D Deficiency in Adult Patients with Schizophreniform and Autism Spectrum Syndromes: A One-Year Cohort Study at a German Tertiary Care Hospital

INTRODUCTION

Vitamin D has many immunomodulatory, anti-inflammatory, and neuroprotective functions, and previous studies have demonstrated an association between vitamin D deficiency and neuropsychiatric disease. The aim of our study was to analyze the prevalence of vitamin D deficiency in a 1-year cohort of adult inpatients with schizophreniform and autism spectrum syndromes in a naturalistic inpatient setting in Germany.

PARTICIPANTS AND METHODS

Our study was comprised of 60 adult schizophreniform and 23 adult high-functioning autism spectrum patients who were hospitalized between January and December of 2015. We compared our findings with a historical German reference cohort of 3,917 adults using Pearson's two-sided chi-squared test. The laboratory measurements of 25-hydroxyvitamin D2/3 [25(OH)vitamin D] were obtained using a chemiluminescence immunoassay.

RESULTS

In the schizophreniform group, we found decreased (<20 ng/ml) 25(OH)vitamin D levels in 48/60 (80.0%) of the patients. In the autism spectrum group, decreased levels were detected in 18/23 (78.3%) of the patients. 25(OH)vitamin D deficiencies were found in 57.3% of the historical control group. Particularly, severe deficiencies (<10 ng/ml) occurred much more frequently in the schizophreniform (38.3%) and autism spectrum groups (52.2%), when compared to the control group (16.3%). The recommended 25(OH)vitamin D values of >30 ng/ml were observed in only 5% of the schizophreniform patients, 8.7% of the autism spectrum patients, and 21.9% of the healthy controls.

DISCUSSION

We found very high rates of 25(OH)vitamin D deficiencies in both patient groups and have discussed whether our findings might be related to alterations in the immunological mechanisms. Irrespective of the possible pathophysiological links between vitamin D deficiency and schizophrenia or autism spectrum disorders, a more frequent measurement of vitamin D levels seems to be justified in these patient groups. Further prospective, controlled, blinded, and randomized research should be conducted to analyze the effectiveness of vitamin D supplementation on the improvement of psychiatric symptoms.