The schizophrenia syndrome, circa 2024: What we know and how that informs its nature

With new data about different aspects of schizophrenia being continually generated, it becomes necessary to periodically revisit exactly what we know. Along with a need to review what we currently know about schizophrenia, there is an equal imperative to evaluate the construct itself. With these objectives, we undertook an iterative, multi-phase process involving fifty international experts in the field, with each step building on learnings from the prior one. This review assembles currently established findings about schizophrenia (construct, etiology, pathophysiology, clinical expression, treatment) and posits what they reveal about its nature. Schizophrenia is a heritable, complex, multi-dimensional syndrome with varying degrees of psychotic, negative, cognitive, mood, and motor manifestations. The illness exhibits a remitting and relapsing course, with varying degrees of recovery among affected individuals with most experiencing significant social and functional impairment. Genetic risk factors likely include thousands of common genetic variants that each have a small impact on an individual's risk and a plethora of rare gene variants that have a larger individual impact on risk. Their biological effects are concentrated in the brain and many of the same variants also increase the risk of other psychiatric disorders such as bipolar disorder, autism, and other neurodevelopmental conditions. Environmental risk factors include but are not limited to urban residence in childhood, migration, older paternal age at birth, cannabis use, childhood trauma, antenatal maternal infection, and perinatal hypoxia. Structural, functional, and neurochemical brain alterations implicate multiple regions and functional circuits. Dopamine D-2 receptor antagonists and partial agonists improve psychotic symptoms and reduce risk of relapse. Certain psychological and psychosocial interventions are beneficial. Early intervention can reduce treatment delay and improve outcomes. Schizophrenia is increasingly considered to be a heterogeneous syndrome and not a singular disease entity. There is no necessary or sufficient etiology, pathology, set of clinical features, or treatment that fully circumscribes this syndrome. A single, common pathophysiological pathway appears unlikely. The boundaries of schizophrenia remain fuzzy, suggesting the absence of a categorical fit and need to reconceptualize it as a broader, multi-dimensional and/or spectrum construct.

Pimavanserin for negative symptoms of schizophrenia: results from the ADVANCE phase 2 randomised, placebo-controlled trial in North America and Europe

BACKGROUND

Negative symptoms of schizophrenia are associated with adverse clinical outcomes, but there are few effective treatments. We aimed to assess the effects of pimavanserin, a selective 5-HT_2A inverse agonist and antagonist, on negative symptoms of schizophrenia.

METHODS

The ADVANCE study was a phase 2, 26-week, randomised, double-blind, placebo-controlled study of pimavanserin in stable outpatients with schizophrenia aged 18-55 years with predominant negative symptoms. Patients were randomly assigned (1:1) across 83 sites (18 in North America and 65 in Europe) to receive pimavanserin or placebo daily, added to an ongoing antipsychotic medication, per a computer-generated schedule (stratification by geographical region). Eligible patients had a score of at least 20 on the sum of seven Positive and Negative Syndrome Scale (PANSS) Marder negative factor items (and scores of ≥4 on at least three or ≥5 on at least two of negative symptom items). The starting dosage of 20 mg of pimavanserin or placebo could be adjusted to 34 mg or 10 mg within the first 8 weeks of the study, after which dosage remained stable until the end of the study. Both pimavanserin and placebo were administered orally once daily as two individual tablets (pimavanserin tablets were either 10 mg or 17 mg). The primary endpoint was change in total score using the 16-item Negative Symptom Assessment (NSA-16) from baseline to week 26. Primary outcomes were analysed in patients who received at least one dose of the study drug and had NSA-16 assessments at baseline and at least once post-baseline (full analysis set). Safety outcomes were analysed in patients who had received at least one dose of the study drug. This trial is registered with ClinicalTrials.gov, NCT02970305, and is complete.

FINDINGS

Between Nov 4, 2016, and April 16, 2019, we randomly assigned 403 patients to pimavanserin (n=201; 131 [65%] male; 187 [93%] White) or placebo (n=202; 137 [68%] male, 186 (92%) White), of whom 400 were included in the efficacy analysis (199 in the pimavanserin group, 201 in the placebo group). Mean age was 37·7 years (SD 9·4) in the pimavanserin group and 36·7 (9·2) years in the placebo group. The change in total NSA-16 score from baseline to week 26 was significantly improved with pimavanserin (least squares mean -10·4 [SE 0·67]) versus placebo (least squares mean -8·5 [0·67]; p=0·043; effect size: 0·211). The number of patients with treatment-emergent adverse events (TEAEs) was similar between groups: 80 (40%) patients experienced TEAEs in the pimavanserin group and 71 (35%) in the placebo group. Most TEAEs were headache (6% [n=13] vs 5% [n=10]) and somnolence (5% [n=11] vs 5% [n=10]). One patient from the placebo group reported severe headache (0·5%), rhinorrhoea (0·5%), cough (0·5%), and influenza (0·5%). In the pimavanserin group, one patient reported severe toothache (0·5%), and two patients had worsening of schizophrenia (1%). Mean change in QTcF interval was higher with pimavanerin (4·5 ms [SD 18·0]) than with placebo (0·0 ms [16·0]).

INTERPRETATION

Stable patients with predominant negative symptoms of schizophrenia showed a reduction in negative symptoms after treatment with pimavanserin. However, given the small effect size, further investigation with optimised dosing is warranted to determine the clinical significance of this effect.

FUNDING

Acadia Pharmaceuticals.

Efficacy of cariprazine on negative symptoms in patients with acute schizophrenia: A post hoc analysis of pooled data

Although currently approved antipsychotics exert efficacy on positive symptoms of schizophrenia, treatments for negative symptoms remain a major unmet need. Post hoc analyses were used to investigate the possible efficacy of cariprazine in patients with moderate/severe negative symptoms of schizophrenia and no predominance of positive symptoms. Data were pooled from 2 randomized, double-blind, placebo- and active-controlled cariprazine studies in patients with acute schizophrenia (NCT00694707, NCT01104766). Analyses included data from a subset of patients with a Positive and Negative Syndrome Scale factor score for negative symptoms (PANSS-FSNS) ≥24, PANSS factor score for positive symptoms (PANSS-FSPS) ≤19, and scores of ≥4 on ≥2 of 3 PANSS items (blunted affect [N1], passive/apathetic social withdrawal [N4], lack of spontaneity/flow of conversation [N6]). Changes from baseline to week 6 in PANSS-FSNS were evaluated in the following treatment groups: placebo (n = 79), cariprazine 1.5-3 (n = 94) and 4.5-6 mg/d (n = 66), risperidone 4 mg/d (n = 34), or aripiprazole 10 mg/d (n = 44). Significant differences were observed versus placebo for cariprazine (1.5-3 mg/d, P = .0179; 4.5-6 mg/d, P = .0002) and risperidone (P = .0149), but not aripiprazole (P = .3265), and versus aripiprazole for cariprazine 4.5-6 mg/d (P = .0197). After adjusting for positive symptom changes, differences versus placebo remained statistically significant for cariprazine (1.5-3 mg/d, P = .0322; 4.5-6 mg/d, P = .0038) but not for risperidone (P = .2204). PANSS-FSNS response (≥20% reduction from baseline) rates were significantly higher with cariprazine (1.5-3 mg/d = 54.3%, P = .0194; 4.5-6 mg/d = 69.7%, P = .0001) than placebo (35.4%). In patients with acute schizophrenia and moderate/severe negative symptoms, cariprazine was associated with significantly greater improvement in negative symptoms compared with placebo and aripiprazole, warranting further exploration of the efficacy of cariprazine on negative symptoms.

The Efficacy of Buprenorphine in Major Depression, Treatment-Resistant Depression and Suicidal Behavior: A Systematic Review

Although several pharmacological options to treat depression are currently available, approximately one third of patients who receive antidepressant medications do not respond adequately or achieve a complete remission. Thus, novel strategies are needed to successfully address those who did not respond, or partially respond, to available antidepressant pharmacotherapy. Research findings revealed that the opioid system is significantly involved in the regulation of mood and incentives salience and may be an appropriate target for novel therapeutic agents. The present study aimed to systematically review the current literature about the use of buprenorphine (BUP) for major depression, treatment-resistant depression (TRD), non-suicidal self-injury (NSSI) behavior, and suicidal behavior. We investigated Pubmed and Scopus databases using the following keywords: "buprenorphine AND depression", "buprenorphine AND treatment resistant depression", "buprenorphine AND suicid*", "buprenorphine AND refractory depression". Several evidence demonstrate that, at low doses, BUP is an efficacious, well-tolerated, and safe option in reducing depressive symptoms, serious suicidal ideation, and NSSI, even in patients with TRD. However, more studies are needed to evaluate the long-term effects, and relative efficacy of specific combinations (e.g., BUP + samidorphan (BUP/SAM), BUP + naloxone (BUP/NAL), BUP + naltrexone) over BUP monotherapy or adjunctive BUP treatment with standard antidepressants, as well as to obtain more uniform guidance about the optimal BUP dosing interval.

Self-Reported Training Adequacy, Experience, and Comfort Level in Performing Schizophrenia-Related Clinical Skills among Psychiatry Residents and Fellows

OBJECTIVE

In the context of an educational program on schizophrenia for psychiatry trainees, this survey study analyzed associations between self-reported training adequacy, experience in providing patient care, and comfort level in performing schizophrenia-related clinical skills. The influence of the education on comfort level was also assessed for each skill.

METHODS

Survey respondents were psychiatry residents and fellows who participated in a schizophrenia education program at an in-person workshop or through online videos recorded at the workshop. In a pre-program survey, participants reported their experience in providing schizophrenia patient care and rated their training adequacy and comfort level for performing seven clinical skills involved in diagnosing and treating schizophrenia. The post-program survey included items for reassessing comfort level in performing the skills.

RESULTS

Across the seven clinical skills, the proportion of respondents (n = 79) who agreed or strongly agreed that their training was adequate ranged from 29 to 88 %. The proportion of high ratings for comfort level in skill performance ranged from 45 to 83 %. Comfort level was significantly associated with training adequacy for all seven clinical skills and with experience in providing patient care for four skills. For all skills, comfort level ratings were significantly higher after versus before the educational workshop. Commonly indicated needs for further training included education on new therapies, exposure to a broader range of patients, and opportunities for longitudinal patient management.

CONCLUSIONS

Psychiatry trainees' self-reported, disease-specific training adequacy, experiences, and comfort level have unique applications for developing and evaluating graduate medical curriculum.

Bitopertin in Negative Symptoms of Schizophrenia-Results From the Phase III FlashLyte and DayLyte Studies

BACKGROUND

There is currently no standard of care for treatment of negative symptoms of schizophrenia, although some previous results with glutamatergic agonists have been promising.

METHODS

Three (SunLyte [WN25308], DayLyte [WN25309], and FlashLyte [NN25310]) phase III, multicenter, randomized, 24-week, double-blind, parallel-group, placebo-controlled studies evaluated the efficacy and safety of adjunctive bitopertin in stable patients with persistent predominant negative symptoms of schizophrenia treated with antipsychotics. SunLyte met the prespecified criteria for lack of efficacy and was declared futile. Key inclusion criteria were age ≥18 years, DSM-IV-TR diagnosis of schizophrenia, score ≥40 on the sum of the 14 Positive and Negative Syndrome Scale negative symptoms and disorganized thought factors, unaltered antipsychotic treatment, and clinical stability. Following a 4-week prospective stabilization period, patients were randomly assigned 1:1:1 to bitopertin (5 mg and 10 mg [DayLyte] and 10 mg and 20 mg [FlashLyte]) or placebo once daily for 24 weeks. The primary efficacy end point was mean change from baseline in Positive and Negative Syndrome Scale negative symptom factor score at week 24.

RESULTS

The intent-to-treat population in DayLyte and FlashLyte included 605 and 594 patients, respectively. At week 24, mean change from baseline showed improvement in all treatment arms but no statistically significant separation from placebo in Positive and Negative Syndrome Scale negative symptom factor score and all other end points. Bitopertin was well tolerated.

CONCLUSIONS

These studies provide no evidence for superior efficacy of adjunctive bitopertin in any of the doses tested over placebo in patients with persistent predominant negative symptoms of schizophrenia.

The Standard for Clinicians' Interview in Psychiatry (SCIP): A Clinician-administered Tool with Categorical, Dimensional, and Numeric Output-Conceptual Development, Design, and Description of the SCIP

Existing standardized diagnostic interviews (SDIs) were designed for researchers and produce mainly categorical diagnoses. There is an urgent need for a clinician-administered tool that produces dimensional measures, in addition to categorical diagnoses. The Standard for Clinicians' Interview in Psychiatry (SCIP) is a method of assessment of psychopathology for adults. It is designed to be administered by clinicians and includes the SCIP manual and the SCIP interview. Clinicians use the SCIP questions and rate the responses according to the SCIP manual rules. Clinicians use the patient's responses to questions, observe the patient's behaviors and make the final rating of the various signs and symptoms assessed. The SCIP method of psychiatric assessment has three components: 1) the SCIP interview (dimensional) component, 2) the etiological component, and 3) the disorder classification component. The SCIP produces three main categories of clinical data: 1) a diagnostic classification of psychiatric disorders, 2) dimensional scores, and 3) numeric data. The SCIP provides diagnoses consistent with criteria from editions of the Diagnostic and Statistical Manual (DSM) and International Classification of Disease (ICD). The SCIP produces 18 dimensional measures for key psychiatric signs or symptoms: anxiety, posttraumatic stress, obsessions, compulsions, depression, mania, suicidality, suicidal behavior, delusions, hallucinations, agitation, disorganized behavior, negativity, catatonia, alcohol addiction, drug addiction, attention, and hyperactivity. The SCIP produces numeric severity data for use in either clinical care or research. The SCIP was shown to be a valid and reliable assessment tool, and the validity and reliability results were published in 2014 and 2015. The SCIP is compatible with personalized psychiatry research and is in line with the Research Domain Criteria framework.

Adjunctive lisdexamfetamine dimesylate therapy in adult outpatients with predominant negative symptoms of schizophrenia: open-label and randomized-withdrawal phases

Negative symptoms of schizophrenia (NSS), related to hypodopaminergic activity in the mesocortical pathway and prefrontal cortex, are predictive of poor outcomes and have no effective treatment. Use of dopamine-enhancing drugs (eg, psychostimulants) has been limited by potential adverse effects. This multicenter study examined lisdexamfetamine dimesylate (LDX), a d-amphetamine prodrug, as adjunctive therapy to antipsychotics in adults with clinically stable schizophrenia and predominant NSS. Outpatients with stable schizophrenia, predominant NSS, limited positive symptoms, and maintained on stable atypical antipsychotic therapy underwent a 3-week screening, 10-week open-label adjunctive LDX (20-70 mg/day), and 4-week, double-blind, randomized, placebo-controlled withdrawal. Efficacy measures included a modified Scale for the Assessment of Negative Symptoms (SANS-18) and Positive and Negative Syndrome Scale (PANSS) total and subscale scores. Ninety-two participants received open-label LDX; 69 received double-blind therapy with placebo (n=35) or LDX (n=34). At week 10 (last observation carried forward; last open-label visit), mean (95% confidence interval) change in SANS-18 scores was -12.9 (-15.0, -10.8; P<0.0001). At week 10, 52.9% of participants demonstrated a minimum of 20% reduction from baseline in SANS-18 score. Open-label LDX was also associated with significant improvement in PANSS total and subscale scores. During the double-blind/randomized-withdrawal phase, no significant differences (change from randomization baseline) were found between placebo and LDX in SANS-18 or PANSS subscale scores. In adults with clinically stable schizophrenia, open-label LDX appeared to be associated with significant improvements in negative symptoms without positive symptom worsening. Abrupt LDX discontinuation was not associated with positive or negative symptom worsening. Confirmation with larger controlled trials is warranted.

A systematic review of psychostimulant treatment of negative symptoms of schizophrenia: challenges and therapeutic opportunities

BACKGROUND

Primary negative symptoms of schizophrenia (NSS) contribute heavily to functional disability and treatment of these symptoms continues to be a major unmet need even when the positive (psychotic) symptoms are controlled. The modified dopamine (DA) hypothesis posits that positive symptoms are associated with increased DA activity in the mesolimbic tract whereas NSS and cognitive symptoms are associated with decreased DA activity in the mesocortical (frontal) region. Several studies have reported improvement in NSS with DA agonist use, but with varying degrees of risk for triggering psychotic symptoms, especially in the absence of concurrent antipsychotic drug treatment. This article aims to examine older and newer evidence suggesting that psychostimulants may have a potential therapeutic role in the treatment of NSS together with a thorough review of the potential risks and benefits of psychostimulant administration in individuals with schizophrenia.

METHODS

A systematic search of relevant literature using electronic databases, reference lists, and data presented at recent meetings was conducted.

RESULTS

Improvement of NSS after psychostimulant administration is reviewed both in challenge and treatment paradigms with various agents such as methylphenidate, amphetamine, and modafinil or armodafinil. The literature points to evidence that, used adjunctively, DA agonists may improve NSS without worsening of positive symptoms in selected patients who are stable and treated with effective antipsychotic medications. Several areas of inadequate study and limitations are identified including small study samples, single-site trials, varying rigor of bias control, the dose and the duration of adjunctive psychostimulant administration, and the potential for development of tolerance.

CONCLUSION

Large, controlled clinical trials to further characterize effects of psychostimulants on NSS in carefully selected patients are warranted.

Heritability of functioning in families with schizophrenia in relation to neurocognition

The role of daily functioning is an integral part of the schizophrenia (SZ) phenotype and deficits in this trait appear to be present in both affected persons and some unaffected relatives; hence we have examined its heritability in our cohort of African American schizophrenia families. There is now ample evidence that deficits in cognitive function can impact family members who are not themselves diagnosed with SZ; there is some, but less evidence that role function behaves likewise. We evaluate whether role function tends to "run in families" who were ascertained because they contain an African American proband diagnosed with SZ.

METHODS

We analyzed heritability for selected traits related to daily function, employment, living situation, marital status, and Global Assessment Scale (GAS) score; modeling age, gender, along with neurocognition and diagnosis as covariates in a family based African-American sample (N=2488 individuals including 979 probands).

RESULTS

Measures of role function were heritable in models including neurocognitive domains and factor analytically derived neurocognitive summary scores and demographics as covariates; the most heritable estimate was obtained from the current GAS scores (h2=0.72). Neurocognition was not a significant contributor to heritability of role function.

CONCLUSIONS

Commonly assessed demographic and clinical indicators of functioning are heritable with a global rating of functioning being the most heritable. Measures of neurocognition had little impact on heritability of functioning overall. The family covariance for functioning, reflected in its heritability, supports the concept that interventions at the family level, such as evidenced-based family psychoeducation may be beneficial in schizophrenia.

The association between weight change and symptom reduction in the CATIE schizophrenia trial

BACKGROUND

Weight gain and changes in metabolic indicators associated with some antipsychotics may be related to symptom improvement and thus an unavoidable correlate of clinical benefit.

METHODS

Data from the CATIE schizophrenia trial comparing the effectiveness of perphenazine, olanzapine, risperidone, quetiapine and ziprasidone in a randomized, double-blind, trial over 18 months were used to evaluate the relationship between percent change in body mass index (BMI) and change in total serum cholesterol and triglycerides with the Positive and Negative Syndrome Scale (PANSS) score. Analysis of covariance for observations at 3 months and a mixed effects model for all observations up to 18 months adjusted for potentially confounding variables were used to examine these associations.

RESULTS

In both models, there was a significant association (p = 0.001) between change in PANSS total score and percent change in BMI, equating to a 0.28 and 0.21 point decrease in PANSS total score (range 30-210) per 1% increase in BMI respectively. Change in BMI accounted for 3% or less of variance for change in PANSS scores. There was no evidence that the association of symptoms and weight gain differed across medications in spite of substantial differences in weight gain and other metabolic measures. Neither total serum cholesterol nor triglyceride levels displayed a significant association with change in PANSS.

CONCLUSION

The magnitude of the relationship between change in BMI and PANSS was too small to be clinically important, indicating that switching medications to one with less metabolic risk is unlikely to result in meaningful loss of clinical benefit.

Suicide Note Classification Using Natural Language Processing: A Content Analysis

Suicide is the second leading cause of death among 25-34 year olds and the third leading cause of death among 15-25 year olds in the United States. In the Emergency Department, where suicidal patients often present, estimating the risk of repeated attempts is generally left to clinical judgment. This paper presents our second attempt to determine the role of computational algorithms in understanding a suicidal patient's thoughts, as represented by suicide notes. We focus on developing methods of natural language processing that distinguish between genuine and elicited suicide notes. We hypothesize that machine learning algorithms can categorize suicide notes as well as mental health professionals and psychiatric physician trainees do. The data used are comprised of suicide notes from 33 suicide completers and matched to 33 elicited notes from healthy control group members. Eleven mental health professionals and 31 psychiatric trainees were asked to decide if a note was genuine or elicited. Their decisions were compared to nine different machine-learning algorithms. The results indicate that trainees accurately classified notes 49% of the time, mental health professionals accurately classified notes 63% of the time, and the best machine learning algorithm accurately classified the notes 78% of the time. This is an important step in developing an evidence-based predictor of repeated suicide attempts because it shows that natural language processing can aid in distinguishing between classes of suicidal notes.

Personal and social functioning in schizophrenia: defining a clinically meaningful measure of maintenance in relapse prevention

BACKGROUND

Relapse prevention and maintenance of social functioning are important treatment objectives in the long-term management of schizophrenia. However, relatively little is known about measuring maintenance of social functioning to assess treatment benefit in relapse prevention clinical trials or as a tool to predict relapse in clinical practice. This study aims (1) to define a clinically meaningful decrease in the Personal and Social Performance scale (PSP) to assess antipsychotic treatment benefit in terms of maintenance of functioning and (2) to explore the threshold value of PSP decline as a useful tool to predict relapse in clinical practice.

METHODS

This post hoc analysis of two similar placebo-controlled relapse prevention clinical trials consisted of an exploration of change in PSP that would represent a clinically important decrement to measure treatment benefit in terms of time to PSP decrement (ITT analysis set; Study 1: n = 205) and an assessment of predictive value of PSP decrement and relapse status (ITT analysis set; Study 2: n = 408).

RESULTS

A 10-point decrement in PSP score was the threshold value for a clinically meaningful decline in personal and social functioning in a relapse prevention trial (Study 1). A strong association was found with relapse status: 61% of subjects with at least a 10-point decrease in PSP experienced the decrement prior to (between start of double-blind phase and before day of relapse) or on the day of relapse (Study 2). Kaplan-Meier survival analysis of time to at least a 10-point decrement in PSP showed that the proportion of subjects who did not experience at least a 10-point PSP decrease was statistically significantly greater in the paliperidone palmitate group than in the placebo group (p = 0.0014) (Study 2).

CONCLUSIONS

Findings suggest a 10-point PSP decrement is a clinically relevant measure of maintenance of functioning in patients stabilized with antipsychotic therapy. Paliperidone palmitate demonstrated a statistically significant treatment benefit in terms of maintenance of functioning versus placebo. Furthermore, measuring a clinically relevant PSP decrement may be useful as an early functional indicator of relapse in clinical practice.

LIMITATIONS

The exploration and validation of the threshold value of change in the PSP was designed and conducted post hoc. Predictive value is limited by the frequency in which PSP assessments were carried out in these trials, underscoring the importance of regular assessment.

Reduced cerebrospinal fluid and plasma nerve growth factor in drug-naïve psychotic patients

Impaired expression and function of several major neurotrophic factors such as nerve growth factor (NGF) has been proposed to contribute to the neurodevelopmental pathology of schizophrenia. However, the evidence in the majority of studies is based on variable and inconsistent levels of plasma NGF in diverse populations of early psychosis or medicated patients with chronic schizophrenia. We report here the first study comparing NGF levels in cerebrospinal fluid (CSF) and plasma from a unique patient cohort (unmedicated, early psychotic patients with similar racial and dietary patterns) and matched healthy controls. Significantly lower levels of NGF in both CSF (p=0.038) and plasma (p=0.002) were observed in drug-naïve first-episode psychosis patients as compared to controls. The levels of NGF in the CSF correlated (p=0.05) to the plasma values in controls. The data on plasma NGF confirm the reported deficits of NGF in drug-naïve first-episode psychosis. The reduced levels first time observed here may have important implications to repeatedly reported neurobiological and clinical deficits which are discussed.

Analysis and utility of pretreatment and posttreatment total body iodine-131 scans in patients with thyroid carcinoma

e17031

Background: The purpose of this study was to evaluate the efficacy of post-I-131 treatment total body scans. Methods: The records of 108 consecutive patients with thyroid carcinoma treated by surgery and postoperative I-131 were reviewed. All patients underwent a postoperative diagnostic total body I-131 and post I-131 therapy scintigraphies .83% of patients were considered low risk according to AMES (age, metastasis, extracapsular extension, size) criteria. Results: The postoperative diagnostic total body I-131 scintigraphy revealed uptake in the neck in 95 out of 108 patients (88%). Three patients had lung and mediastinal uptake in known sites of metastatic disease. Additional foci of neck, mediastinal and lung uptake were revealed in the post-131 therapy total body scintigraphies in ten patients ( 9.3%). Variables found to correlate significantly with additional uptake on the post-I131 therapy total body scintigraphies were tumor size >4cm, lymph-node involvement and extracapsular extension. Conclusions: Post- I-131 therapy scans yielded additional information in 9.3% of the patients treated by postoperative I-131 for well differentiated thyroid carcinoma. The value of posttreatment scintigraphies is questionable in low risk patients.

No significant financial relationships to disclose.

Neoadjuvant docetaxel, cisplatin, and 5-fluorouracil before concurrent chemoradiotherapy or concurrent cetuximab-radiotherapy in locally advanced squamous cell carcinoma of the head and neck

e17045

Background: Encouraging results have recently been reported in patients with locally advanced squamous cell carcinoma of the head and neck. The present study assessed the feasibility of neoadjuvant docetaxel, cisplatin, and 5-fluorouracil (TPF) followed by concurrent chemoradiotherapy (CHT-RT) or concurrent cetuximab-radiotherapy. Methods: Induction chemotherapy consisted of TPF (docetaxel 75 mg/m(2), cisplatin 75 mg/m(2), 5-fluorouracil 750 mg/m(2)/d continuous infusion for 96 h) every three weeks, followed by CHT-RT regimen (radiotherapy 70 Gy total dose fractionated at 2Gy per day, 5 days a week concurrently with weekly cisplatin 40 mg/m(2) or cetuximab with loading dose of 400 one week before starting radiotherapy and 250 weekly during the radiotherapy) 4–7 weeks later. Percutaneus endoscopic gastrectomy inserted before the combined treatment. The National Cancer Institute Common Toxicity Criteria (version 2) were used for classification of adverse events. Results: Between march 2007 and november 2008, 29 previously untreated patients (19 male and 4 female) with stage III-IV squamous cell carcinoma of the oral cavity, larynx, oropharynx, or hypopharynx were included to the study. The median age was 60 years (range, 56–75 years). The stage distribution was as follows: stage II, 1 patient; stage III, 14 patients; and stage IV, 14 patients. 16 patients had a performance status of 0 and 11 had a performance status of 1. The response rate (RR) after IC was: complete response (CR) for 10 pts (34%), partial response (PR) for 13 pts (57%) and no response (NR) for 3 pts (13%). Toxicity from IC included neutropenia Gr III,IV 25%,neutropenic fever 9%, mucositis and diarrhrea Gr III, IV 22% . 60% of patients completed 3 cycles, 20% received 2 cycles and 20% received only one cycle of TPF. The toxicity from the concurrent phase included mucositis Gr III-IV in 70% of patients,dermatitis Gr III-IV in 43% and no case of neutropenia Gr III-IV. The combined treatment was interrupted only in 4 patients for one week. Conclusions: TPF was well tolerated with high response rate and low rate of acute toxicity. Three cycles of TPF followed by combined treatment are feasible.

No significant financial relationships to disclose.

Reliability, validity and ability to detect change of the Personal and Social Performance scale in patients with stable schizophrenia

This report describes the measurement properties of the Personal and Social Performance scale (PSP), a clinician-reported measure of severity of personal and social dysfunction, in an outpatient population with stabilized schizophrenia. Pooled data from two similar antipsychotic clinical studies were analyzed (n=411). The PSP showed good test-retest reliability (intraclass correlation coefficient=0.79). The PSP was more highly correlated with the Strauss-Carpenter Level of Function, an instrument measuring a similar construct, than the Positive and Negative Syndrome Scale, an instrument measuring a different construct. There was a statistically significant difference between mean PSP scores in subjects grouped by their severity rating on the Clinical Global Impression-Severity (CGI-S) (mild or less versus at least moderate), indicating the ability to discriminate between known groups. Effect sizes for mean change in the PSP based on 1-category improvement (0.72) or worsening (-0.88) versus no change in the CGI-S were moderate to large, demonstrating the ability to detect change. Estimates of between-group minimum important difference suggest that a 7-point improvement in the PSP may be clinically meaningful in a clinical trial setting. Initial reliability and validity assessments suggest the PSP may be a useful measure of social functioning in patients with stable schizophrenia.

Growing our own: a regional approach to encourage psychiatric residents to enter research

OBJECTIVE

This article describes a regional program developed by the Department of Veterans Affairs South Central Mental Illness Research, Education and Clinical Center for training psychiatry residents in research and attracting them to academic careers.

METHODS

The authors describe a low-cost, innovative program developed to increase the number of psychiatry residents entering postresidency research training fellowships by providing them with mentorship and exposure to seasoned researchers, didactic coursework, and a stipend to cover academic expenses.

RESULTS

Over the first 4 years, the program has generated enthusiastic participation among postgraduate year 3 (PGY-3) residents, with a high percentage of underrepresented ethnic minorities and women. Products include publication of four first-authored and two coauthored manuscripts, one first-authored abstract, submission of six additional papers, 28 academic presentations and development of research projects. Half of graduating awardees have gone on to pursue research careers.

CONCLUSION

Our regional approach provides sufficient academic expertise to make residency training feasible in a cost-effective manner.

Remission in schizophrenia: applying recent consensus criteria to refine the concept

Although the concept of remission has been widely accepted and utilized in depression and anxiety disorders, there has been much less emphasis on defining remission in schizophrenia. Recently, an expert consensus definition of remission in schizophrenia was proposed along specific operational criteria for the attainment of remission focusing on the three core dimensions of psychopathology identified within schizophrenia: psychoticism, disorganization and negative symptoms. To date, the criteria have been applied retrospectively to several clinical studies, and these have demonstrated that the proposed definition of remission correlates significantly with established measures of symptom severity, functioning and quality of life, and appears achievable for a significant proportion of patients receiving at least 3 months of pharmacotherapy. In this article we extend the notion of remission to include an examination of the possible association of several modifiable and unmodifiable factors and co-morbidities on remission status. We also propose an investigation into the likelihood of different patient populations in achieving remission as well as assessing the impact of remission on health care costs and family burden. Since cognitive dysfunction and negative symptoms may be strongly correlated with a lower likelihood of achieving remission, we recommend retrospective and/or prospective studies to determine the relationship between neurocognitive status and the predominance of negative symptoms at treatment start and the probability of achieving remission. Taken together, these studies should help identify key predictors of remission, further define the remitted state, reduce therapeutic pessimism, raise treatment expectations and chart a strategy for further research in this important area.

Risk of Diabetic Ketoacidosis after Exposure to Risperidone or Olanzapine

BACKGROUND

Atypical antipsychotics have been associated with metabolic abnormalities including impaired glucose metabolism, exacerbation of existing diabetes mellitus and new-onset type 2 diabetes. Not all atypical antipsychotic agents appear to have the same propensity to cause these complications.

OBJECTIVE

To assess diabetic ketoacidosis risk in patients receiving risperidone or olanzapine.

METHODS

California Medicaid data were evaluated for the presence of a diabetic ketoacidosis hospital claim (9th Edition of the International Classification of Diseases code 2501x) for patients receiving an atypical antipsychotic agent between July 1997 and September 2000. Initial prescription claims were identified for risperidone, olanzapine, clozapine, quetiapine and multiple atypical medications; however, the final analysis was restricted to risperidone and olanzapine owing to sample size challenges in the clozapine and quetiapine groups. Cases were specified if a claim occurred within 45 days after antipsychotic dispensation. Potential confounding variables and duration of antipsychotic exposure were included.

RESULTS

Initial users of risperidone (n = 51,330; 31 diabetic ketoacidosis) and olanzapine (n = 51,302; 55 diabetic ketoacidosis) were identified between July 1997 and September 2000. The adjusted risk of diabetic ketoacidosis for olanzapine versus risperidone was 1.62 (p = 0.033). The risk of diabetic ketoacidosis was associated with a longer duration of drug exposure. A progressive and statistically significant divergence in risk was observed between the two treatment groups after the first 30 days of therapy. For risperidone patients, diabetic ketoacidosis risk stabilised after the first 90 days; for olanzapine patients, diabetic ketoacidosis risk continued to increase until 360 days (study duration). For exposures of >30 days, >90 days and >180 days, diabetic ketoacidosis risk was 1.7 (p = 0.026), 2.4 (p = 0.004) and 3.5 (p = 0.001) times greater for olanzapine than risperidone. Treatment group, age, African American race and the presence of schizophrenia or diabetes were significant predictors of diabetic ketoacidosis.

CONCLUSION

The risk of diabetic ketoacidosis appears to be greater for patients exposed to olanzapine compared with risperidone after adjusting for confounding factors. This risk appears to increase with longer duration of exposure to olanzapine.

Assessment of antipsychotic-related risk of diabetes mellitus in a Medicaid psychosis population: Sensitivity to study design

PURPOSE

The effect of study design on findings regarding diabetes risk associated with antipsychotics was studied.

METHODS

This study was a retrospective analysis of data from more than 100,000 Medicaid patients. Diabetes odds ratios (ORs) for patients treated with clozapine, olanzapine, quetiapine, risperidone, ziprasidone, or conventional antipsychotics versus untreated patients were estimated with and without the following design enhancements: screening for preexisting diabetes, selecting for antipsychotic monotherapy, and identifying diabetes with prescription claims only. Logistic regression controlled for patient sex, race and ethnicity, type of psychosis, length of observation and treatment, antipsychotic dosage, pre-existing excess weight or dyslipidemia, and use of other drugs with potential diabetogenic effects.

RESULTS

Under the weakest study design (none of the above enhancements), all antipsychotics were associated with significantly higher odds of diabetes relative to no treatment (p < 0.05). Estimated ORs were as follows: clozapine, 1.468; olanzapine, 1.108; quetiapine, 1.270; ziprasidone, 1.226; risperidone, 1.232; and conventional antipsychotics, 1.159. Under the strongest design (all of the above enhancements), ORs relative to no treatment were significant for clozapine (1.484) and olanzapine (1.149) and nonsignificant for quetiapine (0.998), risperidone (1.124), ziprasidone (0.717), and conventional antipsychotics (1.025). The data also strongly suggest selection bias by clinicians (i.e., selecting antipsychotics based on preexisting diabetes or risk factors for diabetes), disfavoring risperidone and favoring olanzapine. Although the evidence is weaker, quetiapine may also have been affected by unfavorable selection bias.

CONCLUSION

In large database studies, estimated risks of diabetes among patients treated with antipsychotics appeared to be influenced by study design. When a more rigorous design was used, only clozapine and olanzapine were associated with diabetes risk significantly greater than that in untreated patients.

The internal structure of the phenomenology of auditory verbal hallucinations

BACKGROUND

Auditory verbal hallucinations (AVH) do not have uniform pathological significance. They affect patients with different brain disorders, and vary along multiple phenomenological dimensions. Evidence indicates that some of the phenomenological variables have specific neural substrates. Therefore, a comprehensive characterization of the phenomenological variations of AVH and the interrelationship between these variables was undertaken.

METHOD

Twenty phenomenological variables were identified; on each AVH had a binary value (present or absent). Information about 11 of these variables were obtained from 30 patients. Hierarchical cluster (HC) and multidimensional scaling (MDS) analyses were performed to investigate the hidden structure and dimensions of these variables.

RESULTS

HC yielded two main clusters with further sub-clusters in each. The first cluster included hallucinations with low linguistic complexity, repetitive content, attributed to self, located in outer space, and associated with different kinds of control strategies. The second cluster included hallucinations with high linguistic complexity, systematized content, multiple voices, attributed to others, and located in inner space. In MDS, three dimensions were identified: linguistic complexity, self-other attribution, and inner-outer space location.

CONCLUSION

The patterns of clustering and dimensional configuration of AVH characteristics were in accord with intuitive expectation and validated the patients' descriptions of their experiences. These findings could reflect aspects of the neural mechanisms of AVH. For example, the presence of neural specificity for each phenomenological variable, intermediate neural commonality for groups of variables, and a final common pathway for all subtypes of AVH. Another example is a differential level of language dysfunction according to the linguistic complexity of AVH.

A review of the effect of atypical antipsychotics on weight

Controlled research trials have shown that atypical antipsychotics have important advantages over standard antipsychotics, including a broader spectrum of efficacy and improved tolerability profile, particularly with regard to neurological adverse events such as extrapyramidal symptoms (EPS). Some atypical antipsychotics, however, tend to cause significant weight gain, which may lead to poor compliance and other adverse health effects. The mechanisms involved in antipsychotic drug-related weight gain are as yet uncertain, although serotoninergic, histaminic, and adrenergic affinities have been implicated along with other metabolic mechanisms. The atypical antipsychotics vary in their propensity to cause weight change with long-term treatment. Follow-up studies show that the largest weight gains are associated with clozapine and olanzapine, and the smallest with quetiapine and ziprasidone. Risperidone is associated with modest weight changes that are not dose related. Given the equivalent efficacy of atypical antipsychotics, weight-gain profile is a legitimate factor to consider when constructing an algorithm for treatment due to the serious medical consequences of obesity.

Auditory evoked potentials, clinical vs. research applications

Evidence of abnormal auditory evoked potentials (EPs) in patients suffering from schizophrenia has been accumulating. In spite of the magnitude of the EPs in schizophrenia literature, EPs have not been found to be clinically useful thus far. In this study we attempted to replicate the findings in a large sample of schizophrenia patients, and describe how auditory EPs may be used as supplemental tests in the differential diagnostic process. Five subject groups were formed; paranoid (PAR) and disorganized/undifferentiated (disorg/undiff) schizophrenics, schizoaffective (SA), bipolar, and a normal control group. All patients were stable on medications. Subjects underwent one EP recording session. Classification and regression trees (CART) based on EP amplitudes were used to classify subjects into subgroups. The optimal Bayes classification rule that minimizes the expected misclassification cost was then constructed for various misclassification cost functions. In a standard 'Odd Ball' paradigm the N100 amplitudes were significantly decreased in the disorg/undiff group than in the bipolar or normal subjects. The P200 amplitude was smaller in the PAR, disorg/undiff and the SA groups than in the normal controls. Both the disorg/undiff and the PAR groups had significantly lower P300 amplitudes than the normal controls. Classification rules used to classify subjects into normal or ill were sensitive to the relative cost of misclassifying a subject, as well as the prior clinical probability that this subject was ill. Our data largely agree with the existing literature showing abnormally decreased N100, P200, and P300 amplitudes in schizophrenic patients, particularly the disorg/undiff patients. We conclude that whether EP measures are clinically useful depends on the clinical situation. In particular, the prior probability of the diagnosis in question being present and the cost of misclassifying the patient are critical.

Sydenham's chorea and psychopathology

Sydenham's chorea is a movement disorder seen in rheumatic fever with basal ganglia pathology. This disorder has been associated with an increased frequency of psychopathology in both the acute choreiform stage and later in life. We conducted a prospective study of 29 subjects with Sydenham's chorea and 29 age- and sex-matched controls. The total number of psychiatric symptoms 10 years after the initial contact was much greater in the study group than in controls (p less than 0.001). Similarly, schizophrenia was more common in the study group compared to controls (p less than 0.01). Possible neuropathological associations and treatment are discussed.

Leukocyte regulation in depression and schizophrenia

The distribution of leukocytes in the blood stream is affected by levels of circulatory glucocorticoids. Elevated concentrations of cortisol are usually associated with an increase in the number of neutrophils and a decrease in the number of lymphocytes. Since primary depressive illness is often associated with hypercortisolemia, we hypothesized that similar changes in the blood stream of depressive patients may occur. To test this hypothesis, we retrospectively compared leukocyte counts in 177 untreated depressive patients and 178 untreated schizophrenic controls. We found a significant increase in the absolute and relative numbers of neutrophils and a significant decrease in the absolute and relative numbers of lymphocytes in the depressive group. Furthermore, when compared to normative values from the general population, depressed patients showed higher frequencies of both neutrophilia and lymphopenia than the schizophrenic group. These results indicate differences in the regulation of leukocytes in depression and schizophrenia consistent with the effects of higher levels of plasma cortisol in the depressive group.

Unipolar vs. bipolar mania: a review of 247 patients

Previous studies attempting to support unipolar mania as an entity distinct from bipolar disorder, have produced conflicting results. The present study reports on a chart review of 247 patients admitted to the University of Iowa with a history of at least one manic episode; 87 of these had apparently never experienced a depression. A subgroup of 92 patients, who met DSM III diagnostic criteria and had a history of at least two episodes of affective disorder, were also examined. There were few clinically meaningful differences between patients with unipolar mania and bipolar disorder on demographic, symptomatic, or familial variables. An earlier report that unipolar manics were more likely to be male and have a family history of unipolar depression was not confirmed. Unipolar mania is not supported as a separate entity from bipolar disorder.

Wheat gluten challenge in schizophrenic patients

Eight chronic schizophrenic patients were maintained on a diet free of gluten, cereal grains, and milk (CM-F diet) and challenged in a double-blind manner with dietary wheat gluten and placebo. While on the CM-F diet, each patient received a daily challenge of 30 g of gluten for 5 weeks and a placebo challenge for 8 weeks. No deterioration in clinical status as measured by the BPRS was noted on gluten challenge. Serum alpha 1 acid glycoprotein measurement demonstrated no evidence of inflammatory response to gluten challenge. The data suggest that sensitivity to dietary gluten is not characteristic of young chronic schizophrenic patients.

The mathematical case against unipolar mania

A mathematical model is developed based on several assumptions to predict frequency of admission for apparent unipolar mania given that such patients have the same illness as bipolars. The model is compared with data from previous studies of unipolar mania and with data from the author's own study of 77 unipolar manic patients. The observations generally supported the model. It is concluded that the DSM III convention of classifying unipolar manics under the heading "Bipolar disorder" is upheld.

Clinical response and plasma levels: effect of dose, dosage schedules, and drug interactions on plasma chlorpromazine levels

Plasma chlorpromazine (CPZ) levels of 50 psychotic inpatients were measured by gas liquid chromatography; the clinical progress of 29 of these patients with acute psychoses was also assessed. CPZ levels of 50-300 ng/ml were usually associated with clinical improvement; there was also a relationship between CPZ levels and increases in certain symptoms. The 50-300 ng/ml level was best attained by doses of 400-800 mg/day. Trihexyphenidyl decreased plasma CPZ by a mean of 44.7% in 12 of 15 patients. A single 400-800-mg dose of CPZ at bedtime produced steady states equal to or better than those achieved with multiple doses. Those patients who failed to attain CPZ levels of more than 70 ng/ml despite doses of 400-1000 mg/day were receiving lithium throughout the study and had discharge diagnoses of manic-depressive psychosis, manic type, and schizo-affective schizophrenia--a finding with implications for future research.