Prevention of schizophrenia: can it be achieved?

Feasibility of a pharmacist-led physical health monitoring for patients on antipsychotic medications: protocol for a longitudinal study

INTRODUCTION

Physical health conditions are the leading causes of death in people living with severe mental illness. In particular, the risk of metabolic syndrome; the constellation of abnormalities in weight, blood pressure, blood glucose and lipid levels, is high in this cohort. It has been recognised that commonly prescribed pharmacological agents for mental illness can further amplify the risk of developing metabolic syndrome; therefore, monitoring guidelines are in place for consumers prescribed antipsychotics. However, there is a disconnect between recommended guidelines and current practice. Our study aims to investigate: (1) the feasibility of a community pharmacist-led physical health monitoring for metabolic parameters in consumers with mental illness currently taking second generation antipsychotics and (2) the potential outcomes of the intervention (eg, rates and outcome of referrals to general practitioners, relationship between the pharmacist's lifestyle counselling advice and change in metabolic parameters).

METHODS AND ANALYSIS

We propose a longitudinal metabolic monitoring study led by community pharmacists with one-to-one consultations between trained pharmacists and participants at set intervals over a 12-month period. Our primary outcome is to determine the feasibility of the pharmacist-led intervention. The secondary outcome is to explore the overall health outcomes of consumers enrolled in the intervention. This is a mixed-methods study including both quantitative and qualitative outcomes. Qualitative data will be analysed via the process of data immersion, coding and identification of themes. Quantitative outcomes will be analysed using IBM Statistics SPSS software. Univariate descriptive, regression analysis and dependent t-tests will be performed. Statistical significance will be at α 0.05.

ETHICS AND DISSEMINATION

Our study has been approved by the institutional Human Research Ethics Committee (Protocol no: 203433). Findings will be made publicly available in peer-reviewed articles, conference presentations to health professionals, as well as other stakeholders. Protocol V.2.1, August 2021.

TRIAL REGISTRATION NUMBER

ACTRN12621001435875.

Reliability and validity of the Turkish version of comprehensive assessment of at risk mental states

AIMS

To perform the validation of the Comprehensive Assessment at Risk Mental State (CAARMS) in Turkish.

METHODS

Sixty-five volunteers (15-24 years) were enrolled in this study. Concurrent validity was performed with Spearman's Correlation Test using Brief Psychiatric Rating Scale (BPRS). Median scores of the groups were compared using Mann-Whitney U Test. Interrater reliability was assessed by intragroup correlation coefficient method. Internal consistency was studied by the calculation of Cronbach Alfa Coefficient.

RESULTS

The correlation of the severity scores of the CAARMS with unusual thought content, suspiciousness, hallucinations and conceptual disorganization items of the BPRS showed that the concurrent validity was good. ROC analysis revealed that CAARMS could discriminate between individuals with UHR and healthy volunteers well. We found a good correlation between the raters. Internal consistency was at very high level.

CONCLUSION

Analyses of concurrent validity, criterion validity, interrater reliability and internal consistency indicate that the Turkish version is valid and reliable.

'I wanted my child dead' - Physical, social, cognitive, emotional and spiritual life stories of Turkish parents who give care to their children with schizophrenia: A qualitative analysis based on empowerment approach

BACKGROUND

Schizophrenia deeply affects both the lives of patients and their families. The fact that schizophrenic patients in Turkey generally maintain their lives with their families may lead to serious problems for families and parents.

AIMS

The main purposes of this research are to determine the physical, social, cognitive, emotional and spiritual lives of parents of children with schizophrenia with the main concepts of the empowerment approach.

METHOD

The research was carried out with the qualitative research method. In-depth interviews were conducted with 30 parents in total, that is, 15 mothers and 15 fathers, through semi-structured interview form. Maxqda 2018 was used for the analysis of the research data.

RESULTS

According to the research result, it is determined that the parents have problems due to physical, social, cognitive, emotional and spiritual disease process; gender perspective and roles; domestic functionality; social environment, social perception; and issues related to services.

CONCLUSION

Considering the parents who are affected by the disease process which is a particularly quite difficult process and who affect the process, to recognize the situations that lead them to gain strength and that make them powerless in personal, interpersonal and political aspects, to activate the existing resources and to create new resources are highly important factors for them to cope with the disease process effectively.

The Ohio State University Early Psychosis Intervention Center (EPICENTER) step-based care programme for individuals at clinical high risk for psychosis: study protocol for an observational study

INTRODUCTION

In October 2018, the Substance Abuse and Mental Health Services Administration funded 21 sites throughout the USA to develop, implement and evaluate specialised care programmes for individuals at clinical high risk for developing a psychotic disorder (CHR-P). Per the funding requirements, such programmes were required to provide 'step-based care'-a model in which individuals are initially provided with low-intensity, non-psychosis-specific and more benign (ie, least side effects) interventions and only progress onto higher-intensity, psychosis-specific interventions with a greater risk of more severe side effects should they not meet a priori criteria for clinical response to such lower-intensity interventions. Here, we outline the evaluation component of the step-based care programme for individuals at CHR-P at The Ohio State University Early Psychosis Intervention Center (EPICENTER).

METHODS AND ANALYSES

The EPICENTER CHR-P programme provides a step-based care model comprising psychotherapy, medication management, family support/education, peer support and vocational/educational support. All participants who opt to receive care at the EPICENTER will complete a standardised assessment battery as part of usual care. This battery will be administered on enrolment and will be re-administered at 6-month intervals throughout individuals' participation in EPICENTER clinical services. Participants will have the opportunity to allow for data from these usual care assessments to be used as part of an evaluation project for this new clinical service. The primary outcome for this evaluation project is time to remission of symptomatic and functional deficits commonly experienced by individuals at CHR-P. Participants will also have the opportunity to participate in a supplemental research project designed to further evaluate treatment outcomes and patient characteristics among individuals participating in EPICENTER clinical services.

ETHICS AND DISSEMINATION

This project was approved by The Ohio State University Institutional Review Board. Results from this project will be disseminated through publications and presentations.

TRIAL REGISTRATION NUMBER

NCT03970005; Pre-results.

Dietary intervention for people with mental illness in South Australia

Background

People with serious mental illness (SMI) have a 25-30 year lower life expectancy than the general population due largely to cardiovascular disease (CVD). Mediterranean diet can reduce CVD risk and repeat events by 30-70%. We conducted a pilot feasibility study (HELFIMED) with people who have SMI residing within a Community Rehabilitation Centre in South Australia, aimed at improving participants' diets according to Mediterranean diet principles.

Methods

During a 3-month intervention, participants were provided with nutrition education, food hampers, and twice-weekly cooking workshops and guided shopping trips. This report presents the results of a mixed method evaluation of the programme using thorough in-depth interviews with participants and support staff (n = 20), contextualized by changes in dietary biomarkers and CVD risk factors.

Results

The framework thematic analysis revealed evidence of improvements in participants' knowledge of and intake of the key elements of a Mediterranean-style diet (fruit and vegetables, olive oil, fish, legumes), reduction in poor nutrition habits (soft drinks, energy drinks, take away meals) and development of independent living skills-culinary skills such as food preparation and cooking based on simple recipes, food shopping and budgeting, healthy meal planning and social interaction. These changes were supported by dietary biomarkers, and were associated with reduced CVD risk factors.

Conclusions

A Mediterranean diet-based pilot study achieved positive change in dietary behaviours associated with CVD risk for participants with SMI. This supports a need to include dietary education and cooking skills into rehabilitation programmes for people with SMI.

Maternal immune activation leads to increased nNOS immunoreactivity in the brain of postnatal day 2 rat offspring

Neuronal nitric oxide synthase (nNOS) is a key arginine metabolising enzyme in the brain, and nNOS-derived nitric oxide (NO) plays an important role in regulating glutamatergic neurotransmission. NO and its related molecules are involved in the pathogenesis of schizophrenia, and human genetic studies have identified schizophrenia risk genes encoding nNOS. This study systematically investigated how maternal immune activation (MIA; a risk factor for schizophrenia) induced by polyinosinic:polycytidylic acid affected nNOS-immunoreactivity in the brain of the resulting male and female offspring at the age of postnatal day (PND) 2. Immunohistochemistry revealed a markedly increased intensity of nNOS-positive cells in the CA3 and dentate gyrus subregions of the hippocampus, the somatosensory cortex, and the striatum, but not the frontal cortex and hippocampal CA1 region, in the MIA offspring when compared to control group animals. There were no sex differences in the effect. Given the role of nNOS in glutamatergic neurotransmission and its functional relationship with glutamate NMDA receptors, increased nNOS immunoreactivity may indicate the up-regulation of NMDA receptor function in MIA rat offspring at an early postnatal age. Future research is required to determine whether these changes contribute to the neuronal and behavioral dysfunction observed in both juvenile and adult MIA rat offspring.

Developing visually based, low-literacy health education tools for African Americans with psychotic disorders and their families

Schizophrenia presents particular challenges to health literacy, partly due to associated neurocognitive deficits. In order to develop engaging, recovery-oriented, visually based psychoeducational tools pertaining to psychotic disorders, thirty-nine individuals, consisting of mental health service users with serious mental illnesses, family members, and mental health professionals, participated in informal discussions. Using suggestions from these groups, the first two psychoeducational booklets of a planned series were developed in collaboration with a graphic designer and visual artist. Content of the booklets was developed addressing four components: knowledge, self-efficacy/self-management, incorporating a workbook format, and planning/contracting. In a follow-up discussion group, mental health service users provided positive feedback on the completed booklets. The finished booklets are practical, accessible, engaging, and low-literacy. These and other innovative approaches are needed to enhance mental health care, promote self-efficacy/empowerment, and encourage communication between service users, family members, and providers, especially in light of limited health literacy, illness-related neurocognitive impairments, and stigma.

Prevention of the phencyclidine-induced impairment in novel object recognition in female rats by co-administration of lurasidone or tandospirone, a 5-HT(1A) partial agonist

Hypoglutamatergic function may contribute to cognitive impairment in schizophrenia (CIS). Subchronic treatment with the N-methyl-D-aspartate receptor antagonist, phencyclidine (PCP), induces enduring deficits in novel object recognition (NOR) in rodents. Acute treatment with atypical antipsychotic drugs (APDs), which are serotonin (5-HT)(2A)/dopamine D(2) antagonists, but not typical APDs, eg, haloperidol, reverses the PCP-induced NOR deficit in rats. We have tested the ability of lurasidone, an atypical APD with potent 5-HT(1A) partial agonist properties, tandospirone, a selective 5-HT(1A) partial agonist, haloperidol, a D(2) antagonist, and pimavanserin, a 5-HT(2A) inverse agonist, to prevent the development of the PCP-induced NOR deficit. Rats were administered lurasidone (0.1 or 1 mg/kg), tandospirone (5 mg/kg), pimavanserin (3 mg/kg), or haloperidol (1 mg/kg) b.i.d. 30 min before PCP (2 mg/kg, b.i.d.) for 7 days (day1-7), followed by a 7-day washout (day 8-14). Subchronic treatment with PCP induced an enduring NOR deficit. Lurasidone (1 mg/kg) but not 0.1 mg/kg, which is effective to acutely reverse the deficit due to subchronic PCP, or tandospirone, but not pimavanserin or haloperidol, significantly prevented the PCP-induced NOR deficit on day 15. The ability of lurasidone co-treatment to prevent the PCP-induced NOR deficit was enduring and still present at day 22. The preventive effect of lurasidone was blocked by WAY100635, a selective 5-HT(1A) antagonists, further evidence for the importance of 5-HT(1A) receptor stimulation in the NOR deficit produced by subchronic PCP. Further study is needed to determine whether these results concerning mechanism and dosage can be the basis for prevention of the development of CIS in at risk populations.

Early prodromal symptoms can predict future psychosis in familial high-risk youth

BACKGROUND

Efforts to predict psychosis in individuals at high risk for schizophrenia have focused on the identification of sub-threshold clinical criteria and neurobiological markers, including neuropsychological assessment, structural and functional brain imaging, and psychophysiological testing. We sought to evaluate the relative utility of "psychosis-proneness" measures for prospective prediction of psychotic disorders in a group of young relatives at familial risk for schizophrenia.

METHODS

We examined the receiver operating characteristics of sub-threshold symptoms in predicting conversion to psychosis in a group of 97 young first- and second- degree relatives of persons with schizophrenia over a 2-year period. Towards this end, we utilized the Structured Interview of prodromal symptoms to derive measures of two of the four Scale of Prodromal Symptoms subscales (positive and disorganized) and the Chapman Magical Ideation and Perceptual Aberration scales. These four measures were, together, taken to reflect a putative index of psychosis-proneness.

RESULTS

Eleven of the 97 subjects developed a psychotic disorder over 2 years of follow-up. Seventeen of the 97 subjects tested positive on this index of psychosis-proneness at baseline and of these 10 converted to psychosis. The sensitivity and specificity of the test were 91 percent and 92 percent respectively. The positive predictive value of the test was 59 percent and its negative predictive value was 99 percent. Addition of measures of cognitive or social function to the index decreased its predictive ability, reducing its specificity and/or sensitivity.

CONCLUSIONS

A relatively simple set of clinical measures can be utilized to prospectively identify familial high risk individuals who convert to psychosis with high specificity and sensitivity. Implications for the proposed addition of an "attenuated psychosis syndrome" in DSM-5 are discussed.

Attenuated psychosis and the schizophrenia prodrome: current status of risk identification and psychosis prevention

Recent efforts in the prevention of schizophrenia have focused on defining psychosis-risk syndromes and evaluating treatments that can prevent transition to psychosis in these ultra-high risk groups. In this review, different kinds of prevention approaches are enumerated and necessary conditions for a disease-prevention strategy are summarized. The broad overlap as well as the significant difference between a schizophrenia prodrome and a 'psychosis-risk syndrome' is discussed and the present status of approaches to identify individuals at increased risk for developing psychosis and schizophrenia are critically examined along with evaluations on therapeutic interventions to reduce these risks. Finally, to conclude, recommendations for current best clinical practice and key questions for the future are suggested.

Risperidone administered during asymptomatic period of adolescence prevents the emergence of brain structural pathology and behavioral abnormalities in an animal model of schizophrenia

Schizophrenia is a disorder of a neurodevelopmental origin manifested symptomatically after puberty. Structural neuroimaging studies show that neuroanatomical aberrations precede onset of symptoms, raising a question of whether schizophrenia can be prevented. Early treatment with atypical antipsychotics may reduce the risk of transition to psychosis, but it remains unknown whether neuroanatomical abnormalities can be prevented. We have recently shown, using in vivo structural magnetic resonance imaging, that treatment with the atypical antipsychotic clozapine during an asymptomatic period of adolescence prevents the emergence of schizophrenia-like brain structural abnormalities in adult rats exposed to prenatal immune challenge, in parallel to preventing behavioral abnormalities. Here we assessed the preventive efficacy of the atypical antipsychotic risperidone (RIS). Pregnant rats were injected on gestational day 15 with the viral mimic polyriboinosinic-polyribocytidylic acid (poly I:C) or saline. Their male offspring received daily RIS (0.045 or 1.2 mg/kg) or vehicle injection in peri-adolescence (postnatal days [PND] 34-47). Structural brain changes and behavior were assessed at adulthood (from PND 90). Adult offspring of poly I:C-treated dams exhibited hallmark structural abnormalities associated with schizophrenia, enlarged lateral ventricles and smaller hippocampus. Both of these abnormalities were absent in the offspring of poly I:C dams that received RIS at peri-adolescence. This was paralleled by prevention of schizophrenia-like behavioral abnormalities, attentional deficit, and hypersensitivity to amphetamine in these offspring. We conclude that pharmacological intervention during peri-adolescence can prevent the emergence of behavioral abnormalities and brain structural pathology resulting from in utero insult. Furthermore, highly selective 5HT(2A) receptor antagonists may be promising targets for psychosis prevention.

Tracing the development of psychosis and its prevention: what can be learned from animal models

Schizophrenia (SCZ) is a neurodevelopmental disorder manifested symptomatically after puberty whose pharmacotherapy remains unsatisfactory. In recent years, longitudinal structural neuroimaging studies have revealed that neuroanatomical aberrations occur in this disorder and in fact precede symptom onset, raising the exciting possibility that SCZ can be prevented. There is some evidence that treatment with atypical antipsychotic drugs (APDs) prior to the development of the full clinical phenotype reduces the risk of transition to psychosis, but results remain controversial. It remains unknown whether progressive structural brain aberrations can be halted. Given the diagnostic, ethical, clinical and methodological problems of pharmacological and imaging studies in patients, getting such information remains a major challenge. Animal neurodevelopmental models of SCZ are invaluable for investigating such questions because they capture the notion that the effects of early brain damage are progressive. In recent years, data derived from such models have converged on key neuropathological and behavioral deficits documented in SCZ attesting to their strong validity, and making them ideal tools for evaluating progression of pathology following in-utero insults as well as its prevention. We review here our recent studies that use longitudinal in vivo structural imaging to achieve this aim in the prenatal immune stimulation model that is based on the association of prenatal infection and increased risk for SCZ. Pregnant rats were injected on gestational day 15 with the viral mimic polyriboinosinic-polyribocytidylic acid (poly I:C) or saline. Male and female offspring were imaged and tested behaviorally on postnatal days (PNDs) 35, 46, 56, 70 and 90. In other experiments, offspring of poly I:C- and saline-treated dams received the atypical antipsychotic drugs (APDs) clozapine or risperidone in two developmental windows: PND 34-47 and PND 48-61, and underwent behavioral testing and imaging at adulthood. Prenatal poly I:C-induced interference with fetal brain development led to aberrant postnatal brain development as manifested in structural abnormalities in the hippocampus, the striatum, the prefrontal cortex and lateral ventricles (LV), as seen in SCZ. The specific trajectories were region-, age- and sex-specific, with females having delayed onset of pathology compared to males. Brain pathology was accompanied by development of behavioral abnormalities phenotypic of SCZ, attentional deficit and hypersensitivity to amphetamine, with same sex difference. Hippocampal volume loss and LV volume expansion as well as behavioral abnormalities were prevented in the offspring of poly I:C mothers who received clozapine or risperidone during the asymptomatic period of adolescence (PND 34-47). Administration at a later window, PNDs 48-61, exerted sex-, region- and drug- specific effects. Our data show that prenatal insult leads to progressive postnatal brain pathology, which gradually gives rise to "symptoms"; that treatment with atypical APDs can prevent both brain and behavioral pathology; and that the earlier the intervention, the more pathological outcomes can be prevented.

If waking and dreaming consciousness became de-differentiated, would schizophrenia result?

If both waking and dreaming consciousness are functional, their de-differentiation would be doubly detrimental. Differentiation between waking and dreaming is achieved through neuromodulation. During dreaming, without external sensory data and with mesolimbic dopaminergic input, hyper-cholinergic input almost totally suppresses the aminergic system. During waking, with sensory gates open, aminergic modulation inhibits cholinergic and mesocortical dopaminergic suppresses mesolimbic. These neuromodulatory systems are reciprocally interactive and self-organizing. As a consequence of neuromodulatory reciprocity, phenomenologically, the self and the world that appear during dreaming differ from those that emerge during waking. As a result of self-organizing, the self and the world in both states are integrated. Some loss of self-organization would precipitate a degree of de-differentiation between waking and dreaming, resulting in a hybrid state which would be expressed heterogeneously, both neurobiologically and phenomenologically. As a consequence of progressive de-differentiation, certain identifiable psychiatric disorders may emerge. Ultimately, schizophrenia, a disorganized-fragmented self, may result.

Ways of coping in adolescents with schizophrenia

The purpose of this study was to explore ways of coping and its association with specific stress responses in adolescents with schizophrenia. Additionally, subjects and healthy controls were compared to identify stress responses. Forty subjects were drawn from a self-management therapy study for youth with schizophrenia. Thirty community-dwelling controls were selected. A revised Ways of Coping scale and the Symptom of Stress at baseline, 6, 30 and 54 weeks measured coping and stress response. Descriptive statistics, cluster analysis and Pearson correlation provided data analysis. Thirty-two subjects were male, and eight were female. Average age was 17.25 (SD=1.37) years. Twenty-two (55%) were Caucasian; 18 (45%) were non-Caucasian. Seventeen (57%) of the 30 controls were female. The mean age was 17.10 years old (SD=1.16). Adolescents with schizophrenia used emotion-focused coping more than problem-focused coping at baseline and 6 weeks (P<0.01). Subjects reported higher stress than controls (t=4.73, P<0.01) and used emotion-focused coping with emotional stress responses (r=0.34, P=0.05). Adolescent coping strategies may persist into adulthood unless new skills are introduced. Developing effective coping skills for adolescents with schizophrenia is important for practice and future studies.

Beliefs about causes of schizophrenia among urban African American community members

The public's causal attributions of schizophrenia have far-reaching effects on the community and affected individuals. This study investigated causal beliefs within a community of predominantly Protestant, low-income, urban, African Americans in the southeastern United States. Two hundred eighty-two patrons of an inner-city food court/farmers' market participated in a self-administered survey assessing causal beliefs through a 30-item survey and self-reported causal opinions. Associations were assessed between causal attributions of schizophrenia and sociodemographic characteristics and exposure/familiarity variables. Certain sociodemographic variables, as well as key exposure/familiarity variables, predicted the nature of one's causal beliefs. The most common causal opinions reported included substance abuse, negative life events, and "mental illness." Findings from a subsample administered an exploratory multiple-choice question investigating understanding of causation revealed that the public may not fully understand the nature of causation. Although this study suggests potential determinants of causal beliefs held by community members, further research examining the public's conception of causation would enhance interpretation of studies on such beliefs.

A Hybrid Machine Learning Method for Fusing fMRI and Genetic Data: Combining both Improves Classification of Schizophrenia

We demonstrate a hybrid machine learning method to classify schizophrenia patients and healthy controls, using functional magnetic resonance imaging (fMRI) and single nucleotide polymorphism (SNP) data. The method consists of four stages: (1) SNPs with the most discriminating information between the healthy controls and schizophrenia patients are selected to construct a support vector machine ensemble (SNP-SVME). (2) Voxels in the fMRI map contributing to classification are selected to build another SVME (Voxel-SVME). (3) Components of fMRI activation obtained with independent component analysis (ICA) are used to construct a single SVM classifier (ICA-SVMC). (4) The above three models are combined into a single module using a majority voting approach to make a final decision (Combined SNP-fMRI). The method was evaluated by a fully validated leave-one-out method using 40 subjects (20 patients and 20 controls). The classification accuracy was: 0.74 for SNP-SVME, 0.82 for Voxel-SVME, 0.83 for ICA-SVMC, and 0.87 for Combined SNP-fMRI. Experimental results show that better classification accuracy was achieved by combining genetic and fMRI data than using either alone, indicating that genetic and brain function representing different, but partially complementary aspects, of schizophrenia etiopathology. This study suggests an effective way to reassess biological classification of individuals with schizophrenia, which is also potentially useful for identifying diagnostically important markers for the disorder.

Evaluating early preventive antipsychotic and antidepressant drug treatment in an infection-based neurodevelopmental mouse model of schizophrenia

Current pharmacotherapy of schizophrenia remains unsatisfactory with little hope for complete functional restoration in patients once the disease has developed. A preventive approach based on intervention in the prodromal stage of the disease aiming to preserve functional integrity by halting the progress of the disease is therefore extremely attractive. Here, we investigated the effects of preventive antipsychotic or antidepressant drug treatment in a well-established neurodevelopmental mouse model of multiple schizophrenia-related abnormalities. Pregnant mice on gestation day 9 were exposed to the viral mimic polyriboinosinic-polyribocytidylic acid (2 mg/kg, intravenously) or corresponding vehicle treatment, and the resulting offspring from both prenatal treatment conditions were subjected to chronic antipsychotic (haloperidol or clozapine), antidepressant (fluoxetine), or placebo treatment during the periadolescent stage of development. The effects of the preventive pharmacotherapy on behavioral and pharmacological functions were then investigated in adulthood using paradigms relevant to schizophrenia, namely prepulse inhibition, latent inhibition, and sensitivity to psychostimulant drugs. We show that periadolescent treatment with the reference antipsychotic and antidepressant drugs can successfully block the emergence of multiple psychosis-related behavioral and pharmacological abnormalities in subjects predisposed to adult brain pathology by exposure to prenatal immune challenge. At the same time, however, our study reveals numerous negative influences of the early pharmacological intervention on normal behavioral development in control subjects. Hence, even though preventive pharmacotherapy may be beneficial in individuals with predisposition to psychosis-related brain dysfunctions, chronic antipsychotic or antidepressant drug treatment in false-positive subjects is associated with substantial risk for long-term behavioral disturbances in adulthood.

Research in people with psychosis risk syndrome: a review of the current evidence and future directions

After decades of research, schizophrenia and related psychotic disorders are still among the most debilitating disorders in medicine. The chronic illness course in most individuals, greater treatment responsiveness during the first episode, progressive gray matter decline during early disease stages, and retrospective accounts of 'prodromal' or early illness signs and symptoms formed the basis for research on the psychosis risk syndrome (PRS), known variably as 'clinical high risk' (CHR), or 'ultra-high risk' (UHR), or 'prodromal'. The pioneering era of research on PRS focused on the development and validation of specific assessment tools and the delineation of high risk criteria. This was followed by the examination of conversion rates in psychosis risk cohorts followed naturalistically, identification of predictors of conversion to psychosis, and investigation of interventions able to abort or delay the development of full psychosis. Despite initially encouraging results concerning the predictive validity of PRS criteria, recent findings of declining conversion rates demonstrate the need for further investigations. Results from intervention studies, mostly involving second-generation antipsychotics and cognitive behavioral therapy, are encouraging, but are currently still insufficient to make treatment recommendations for this early, relatively non-specific illness phase. The next phase of research on PRS, just now beginning, has moved to larger, 'multisite' projects to increase generalizability and to ensure that sufficiently large samples at true risk for psychosis are included. Emphasis in these emerging studies is on: 1) identification of biomarkers for conversion to psychosis; 2) examination of non-antipsychotic, neuroprotective and low-risk pharmacologic and non-pharmacologic interventions; 3) testing of potentially phase-specific interventions; 4) examination of the relationship between treatment response during PRS and prognosis for the course of illness; 5) follow-up of patients who developed schizophrenia despite early interventions and comparison of illness trajectories with patients who did not receive early interventions; 6) characterization of individuals with outcomes other than schizophrenia-spectrum disorders, such as bipolar disorder and remission from PRS, including false positive cases; and 7) assessment of meaningful social and role functioning outcomes. While the research conducted to date has already yielded crucial information, the translation of the concept of a clinically identifiable PRS into clinical practice does not seem justified at this point.

The relationship between symptoms and stress in adolescents with schizophrenia

Stress predicts outcomes in adults with schizophrenia, but its effect in adolescents is unknown. We used exploratory data analysis to examine changes in symptoms and to correlate symptoms with stress at 0, 6, 30, and 54 weeks in 40 adolescents with schizophrenia. Symptoms were measured with the Early Signs and Symptoms Scale; stress was measured with the Hassles Scale. From baseline to 54 weeks, symptom severity decreased significantly. Symptom severity and stress correlated significantly at baseline, 30 weeks, and 54 weeks, after controlling for the number of hospitalizations and baseline symptom severity. These results implicate stress in schizophrenia symptoms in adolescents and justify examining stress management for these patients.

Clozapine administration in adolescence prevents postpubertal emergence of brain structural pathology in an animal model of schizophrenia

BACKGROUND

Schizophrenia is a neuropsychiatric disorder of a neurodevelopmental origin manifested symptomatically after puberty. Structural neuroimaging studies show that neuroanatomical aberrations occur before onset of symptoms, raising a question of whether schizophrenia can be prevented. Treatment with atypical antipsychotic drugs before the development of the full clinical phenotype might reduce the risk of transition to psychosis, but it remains unknown whether neuroanatomical abnormalities can be prevented. We used a neurodevelopmental animal model of schizophrenia to assess the efficacy of the atypical antipsychotic clozapine to prevent neuroanatomical deterioration.

METHODS

Pregnant rats received injection on gestational day 15 with the viral mimic polyriboinosinic-polyribocytidylic acid (PolyI:C) or saline. Structural brain changes in the male offspring were assessed at adolescence and adulthood (35 days and 120 days) with structural neuroimaging. In the second part, male offspring of PolyI:C- and saline-treated dams received daily clozapine (7.5 mg/kg) or saline injection in adolescence (days 34-47) and underwent behavioral testing and imaging at adulthood (from 90 days onward).

RESULTS

In utero exposure to maternal infection led in the offspring to postpubertal emergence of hallmark structural abnormalities associated with schizophrenia, enlarged ventricles, and smaller hippocampus. These abnormalities were not observed in the offspring of mothers who received PolyI:C that were treated with clozapine in adolescence. This was paralleled by prevention of behavioral abnormalities phenotypic of schizophrenia, attentional deficit, and hypersensitivity to amphetamine.

CONCLUSIONS

This is the first demonstration that pharmacological intervention during adolescence can prevent the emergence of brain structural changes resulting from in-utero insult.

Comparison of Attitudes of Psychiatrists vs Primary Healthcare Physicians in Singapore Towards At Risk Mental States (ARMS)

Aims: It is possible to define at risk mental states (ARMS) that predict conversion to schizophrenia in up to 40% of help seeking individuals within a year of screening. Treatment of ARMS is controversial due to difficulties with diagnosis and uncertainties of treatment effective- ness. This survey was conducted to assess and compare attitudes of Singapore psychiatrists vs primary healthcare physicians towards ARMS. Materials and Methods: An anonymous survey containing a clinical vignette and questions related to the diagnosis and management of ARMS was sent out to all registered psychiatrists/ psychiatry trainees and all doctors in a public primary healthcare group in Singapore. Results: The response rate was 62.1% (87/140) and 72.3% (107/ 148) for psychiatrists and primary healthcare physicians respectively. The proportion of psychiatrists diagnosing ARMS vs psychosis was 44.8% vs 43.7% respectively. Among primary care physicians, the corresponding proportion was 54.2% vs 40.2%. The difference between the 2 groups did not reach statistical significance. Among psychiatrists who diagnosed ARMS, 74.4% (29/39) would treat the patient with active management. Of the total number of psychiatrists surveryed, 49.4% would advocate population screening of high risk groups compared to 30.8% of primary healthcare physicians. And 64.4% of psychiatrists felt that there was no consensus regarding the management of ARMS. Conclusions: There is currently clinical equipoise with regards to both diagnosis and management of ARMS in Singapore. Primary care physicians may be more likely to diagnose psychosis vs ARMS when compared to psychiatrists. Psychiatrists were more likely than primary healthcare physicians to advocate population screening of ARMS in high-risk groups. Most psychiatrists would manage ARMS actively. Key words: Prodrome, Schizophrenia

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

Combining fMRI and SNP data to investigate connections between brain function and genetics using parallel ICA

There is current interest in understanding genetic influences on both healthy and disordered brain function. We assessed brain function with functional magnetic resonance imaging (fMRI) data collected during an auditory oddball task--detecting an infrequent sound within a series of frequent sounds. Then, task-related imaging findings were utilized as potential intermediate phenotypes (endophenotypes) to investigate genomic factors derived from a single nucleotide polymorphism (SNP) array. Our target is the linkage of these genomic factors to normal/abnormal brain functionality. We explored parallel independent component analysis (paraICA) as a new method for analyzing multimodal data. The method was aimed to identify simultaneously independent components of each modality and the relationships between them. When 43 healthy controls and 20 schizophrenia patients, all Caucasian, were studied, we found a correlation of 0.38 between one fMRI component and one SNP component. This fMRI component consisted mainly of parietal lobe activations. The relevant SNP component was contributed to significantly by 10 SNPs located in genes, including those coding for the nicotinic alpha-7 cholinergic receptor, aromatic amino acid decarboxylase, disrupted in schizophrenia 1, among others. Both fMRI and SNP components showed significant differences in loading parameters between the schizophrenia and control groups (P = 0.0006 for the fMRI component; P = 0.001 for the SNP component). In summary, we constructed a framework to identify interactions between brain functional and genetic information; our findings provide a proof-of-concept that genomic SNP factors can be investigated by using endophenotypic imaging findings in a multivariate format.

Physiogenomic analysis of localized FMRI brain activity in schizophrenia

The search for genetic factors associated with disease is complicated by the complexity of the biological pathways linking genotype and phenotype. This analytical complexity is particularly concerning in diseases historically lacking reliable diagnostic biological markers, such as schizophrenia and other mental disorders. We investigate the use of functional magnetic resonance imaging (fMRI) as an intermediate phenotype (endophenotype) to identify physiogenomic associations to schizophrenia. We screened 99 subjects, 30 subjects diagnosed with schizophrenia, 13 unaffected relatives of schizophrenia patients, and 56 unrelated controls, for gene polymorphisms associated with fMRI activation patterns at two locations in temporal and frontal lobes previously implied in schizophrenia. A total of 22 single nucleotide polymorphisms (SNPs) in 15 genes from the dopamine and serotonin neurotransmission pathways were genotyped in all subjects. We identified three SNPs in genes that are significantly associated with fMRI activity. SNPs of the dopamine beta-hydroxylase (DBH) gene and of the dopamine receptor D4 (DRD4) were associated with activity in the temporal and frontal lobes, respectively. One SNP of serotonin-3A receptor (HTR3A) was associated with temporal lobe activity. The results of this study support the physiogenomic analysis of neuroimaging data to discover associations between genotype and disease-related phenotypes.

DSM-V research agenda: substance abuse/psychosis comorbidity

For diagnosis of patients with comorbid psychotic symptoms and substance use disorders (SUDs), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, makes clear distinctions between independent psychotic disorders (eg, bipolar disorder, schizophrenia) and substance-induced syndromes (eg, delirium, dementias). Most substance-induced psychotic symptoms are considered to be short lived and to resolve with sustained abstinence along with other symptoms of substance intoxication and withdrawal. These guidelines are challenged by practical difficulties in distinguishing between substance-induced and independent psychoses and by mounting evidence that marijuana use may be a contributing cause of schizophrenia. To inform the diagnostic distinction between substance-induced vs independent psychotic symptoms, 2 kinds of information could be sought from longitudinal research: (a) identification of early markers that clearly differentiate the 2 conditions and (b) more precise information about duration of psychotic symptoms induced by different substances. Evidence of this type could emerge from reanalysis of existing data from large-scale longitudinal studies of community samples. To inform possible nosological changes related to the possible schizophrenia-inducing role of marijuana (eg, designating a "cannabis-induced" subtype), a wide range of research evidence will be needed to clarify the relationship between effects of cannabis and schizophrenia symptoms. Ultimately, the ideal psychiatric nomenclature will define syndromes on the basis of established etiology and/or pathophysiology. Given the strong association between SUDs and psychotic disorders, research on the neurobiology of psychotic disorders could fruitfully include subjects with comorbid SUDs to shed light on shared etiology and pathophysiology.

Bedeutung von Psychotherapie in der Versorgung von Menschen mit schizophrenen Störungen in Deutschland

BACKGROUND

Little is known about the degree of implementation of evidence-based psychotherapy in routine care of people with schizophrenia in Germany.

METHOD

First, results of studies on the efficacy of psychotherapy in the treatment of schizophrenia are summarised. Second, the degree of implementation of psychotherapeutic practices in the routine care of schizophrenics is assessed through a systematic literature search and analyses of several data sets.

RESULTS

There is substantial evidence for the efficacy of cognitive-behavioural interventions in the treatment of schizophrenia. The paucity of data on the degree of implementation suggests a wide gap between evidence and practice.

CONCLUSIONS

Barriers to implementation are outlined and discussed. There is a need for more studies on epidemiological and long-term effectiveness of health care.

Prospective investigations of the prodromal state of schizophrenia: review of studies

OBJECTIVE

The paper presents a comprehensive overview of prospective studies monitoring or intervening in the pre-onset phase of first episode psychosis.

METHOD

A systematic literature search was conducted and supplemented by a manual search. All relevant studies were ordered and intensively reviewed according to specified criteria. Methodological and conceptual issues are discussed.

RESULTS

Reports of 23 prospective studies were found, some describing subsamples of larger samples. Major methodological and conceptual divergences exist.

CONCLUSION

Applied criteria detect individuals with a significantly increased risk of psychosis within the schizophrenia spectrum, but these criteria are only validated on clinical populations. The significance of differences in sample-characteristics is unclear. Most study samples are small. Results are preliminary and in need of further research before they constitute a realistic knowledge base. Methodological and conceptual issues should not be underestimated.