An open-label study of algorithm-based treatment versus treatment-as-usual for patients with schizophrenia

OBJECTIVE

The use of an algorithm may facilitate measurement-based treatment and result in more rational therapy. We conducted a 1-year, open-label study to compare various outcomes of algorithm-based treatment (ALGO) for schizophrenia versus treatment-as-usual (TAU), for which evidence has been very scarce.

METHODS

In ALGO, patients with schizophrenia (Diagnostic and Statistical Manual of Mental Disorders, fourth edition) were treated with an algorithm consisting of a series of antipsychotic monotherapies that was guided by the total scores in the positive and negative syndrome scale (PANSS). When posttreatment PANSS total scores were above 70% of those at baseline in the first and second stages, or above 80% in the 3rd stage, patients proceeded to the next treatment stage with different antipsychotics. In contrast, TAU represented the best clinical judgment by treating psychiatrists.

RESULTS

Forty-two patients (21 females, 39.0 ± 10.9 years-old) participated in this study. The baseline PANSS total score indicated the presence of severe psychopathology and was significantly higher in the ALGO group (n = 25; 106.9 ± 20.0) than in the TAU group (n = 17; 92.2 ± 18.3) (P = 0.021). As a result of treatment, there were no significant differences in the PANSS reduction rates, premature attrition rates, as well as in a variety of other clinical measures between the groups. Despite an effort to make each group unique in pharmacologic treatment, it was found that pharmacotherapy in the TAU group eventually became similar in quality to that of the ALGO group.

CONCLUSION

While the results need to be carefully interpreted in light of a hard-to-distinguish treatment manner between the two groups and more studies are necessary, algorithm-based antipsychotic treatments for schizophrenia compared well to treatment-as-usual in this study.

Effects of menopause on brain structural changes in schizophrenia

AIM

The aim of this study was to investigate the influences of menopause on brain morphological changes in schizophrenia using magnetic resonance imaging (MRI).

METHODS

Forty female schizophrenia patients, 20 premenopausal and 20 postmenopausal, and 50 female controls underwent cerebral MRI. Optimized voxel-based morphometry was performed with Statistical Parametric Mapping version 5.

RESULTS

Compared with controls, regional gray matter reductions in schizophrenia patients were observed in the insula, superior temporal gyrus, anterior cingulate, parahippocampal gyrus, and thalamus. Direct comparison between the patient groups showed that the gray matter of postmenopausal patients was significantly smaller when compared with premenopausal patients in the left middle frontal gyrus, and no region had significantly lower gray matter volume in premenopausal patients relative to postmenopausal patients. Significant negative correlation between gray matter volume and the interval after menopause was found in the right superior frontal gyrus in the postmenopause patient group.

CONCLUSION

Differential morphological alterations between postmenopausal and premenopausal schizophrenia patients were observed, suggesting that the female hormone plays a protective role against schizophrenia.

[Cenesthopathy in the presenium associated with manic factor resolved with lithium carbonate: two female cases with underlying manic or mixed state]

Cenesthopathy is a syndrome where patients persistently complain of abnormal sensations in some particular parts of their body, giving them odd descriptions, with the sensations being medically unexplainable. It is also often chronic and refractory to treatment It is commonly divided into two types: one is defined in a narrow sense, with only an abnormal sensation of the body as the main symptom, and the other in a wider sense, where the sensation is a syndrome accompanying schizophrenia, depression, or organic psychiatric disorder. The nosological evaluation of cenesthopathy has not been established. We report two pre-senile female patients with cenesthopathy under agitated conditions continuing for years, with a diagnosis of depression, and they were resolved with lithium carbonate administered for a manic or mixed state exhibited later. There have been few reports on cenesthopathy accompanying a manic or mixed state, or the effect of lithium carbonate on such a condition. Our cases showed that a manic factor or mixed state plays an important role in agitated symptoms often observed in pre-senile and senile depression. We propose that the hypochondriacal state involving cenesthopathy may be strongly associated with a manic factor, as has been psychopathologically discussed in foreign and domestic literature, including studies of Ey, H. and Leonhard, K. Although cenesthopathy has been mainly treated with antidepressants and antipsychotics, considering the weight of a manic factor and mixed state, mood stabilizers such as lithium carbonate at an adequate dosage may prove to be effective.

Influence of contact with schizophrenia on implicit attitudes towards schizophrenia patients held by clinical residents

BACKGROUND

Patients with schizophrenia and their families have suffered greatly from stigmatizing effects. Although many efforts have been made to eradicate both prejudice and stigma, they still prevail even among medical professionals, and little is known about how contact with schizophrenia patients affects their attitudes towards schizophrenia.

METHODS

We assessed the impact of the renaming of the Japanese term for schizophrenia on clinical residents and also evaluated the influence of contact with schizophrenia patients on attitudes toward schizophrenia by comparing the attitudes toward schizophrenia before and after a one-month clinical training period in psychiatry. Fifty-one clinical residents participated. Their attitudes toward schizophrenia were assessed twice, before and one month after clinical training in psychiatry using the Implicit Association Test (IAT) as well as Link's devaluation-discrimination scale.

RESULTS

The old term for schizophrenia, "Seishin-Bunretsu-Byo", was more congruent with criminal than the new term for schizophrenia, "Togo-Shitcho-Sho", before clinical training. However, quite opposite to our expectation, after clinical training the new term had become even more congruent with criminal than the old term. There was no significant correlation between Link's scale and IAT effect.

CONCLUSIONS

Renaming the Japanese term for schizophrenia still reduced the negative images of schizophrenia among clinical residents. However, contact with schizophrenia patients unexpectedly changed clinical residents' attitudes towards schizophrenia negatively. Our results might contribute to an understanding of the formation of negative attitudes about schizophrenia and assist in developing appropriate clinical training in psychiatry that could reduce prejudice and stigma concerning schizophrenia.

The characteristics of serious suicide attempters in Japanese adolescents--comparison study between adolescents and adults

BACKGROUND

Suicide is the leading cause of death among Japanese adolescents, and they may commit suicide differently from adults. However, there are few studies in medical-based data concerning adolescent patients seriously attempting suicide. We aimed to explore the characteristics of serious suicide attempts in Japanese adolescents, comparing them with those in adults.

METHODS

We investigated adolescents who seriously attempted suicide and were treated at the Critical Care Medical Center (CCMC) of Nippon Medical School Hospital between 2000 and 2010, and we compared them with adult suicide attempters treated during 2009. We retrospectively studied medical records and collected clinical data and socio-demographic factors, including age, sex, psychiatric symptoms or diagnosis, methods of suicide attempt, motives for suicide attempt, previous deliberate self-harm, previous psychiatric history, parent loss experience, and previous psychiatric history in the family.

RESULTS

Adolescent attempters were 15 males and 44 females, 13 to 18 years old (mean 16.39). Adult attempters were 37 males and 65 females, 19 to 79 years old (mean 39.45). In comparison to adult attempters, adolescent attempters were more frequently diagnosed with Borderline Personality Disorder (BPD), had more school problems and parent loss experience, but they had less financial problems. Gender differences between adolescents and adults were examined, and male adolescent attempters were found to be more frequently diagnosed with schizophrenia and had less financial problems than their adult counterparts, while female adolescent attempters were more frequently diagnosed with BPD, had more school problems and parent loss, but they had less previous psychiatric history than their adult counterparts.

CONCLUSIONS

Our findings indicated that adolescent attempters were more frequently diagnosed with BPD and had more school problems and parent loss experience but had less financial problems. Additionally, in male adolescent attempters, identifying patients with schizophrenia seemed important, as it was their most frequent psychiatric diagnosis. For female adolescents, adequately assessing family function and interpersonal conflicts seemed important, as they were more often diagnosed with BPD and had more school and family problems.

The effects of C-type natriuretic peptide on craniofacial skeletogenesis

C-type natriuretic peptide (CNP) is a potent stimulator of long bone and vertebral development via endochondral ossification. In the present study, we investigated the effects of CNP on craniofacial skeletogenesis, which consists of both endochondral and membranous ossification. Morphometric analyses of crania from CNP knockout and transgenic mice revealed that CNP stimulates longitudinal growth along the cranial length, but does not regulate cranial width. CNP markedly increased the length of spheno-occipital synchondrosis in fetal murine organ cultures, and the thickness of cultured murine chondrocytes from the spheno-occipital synchondrosis or nasal septum, resulting in the stimulation of longitudinal cranial growth. Mandibular growth includes endochondral and membranous ossification; although CNP stimulated endochondral bone growth of condylar cartilage in cultured fetal murine mandibles, differences in the lengths of the lower jaw between CNP knockout or transgenic mice and wild-type mice were smaller than those observed for the lengths of the upper jaw. These results indicate that CNP primarily stimulates endochondral ossification in the craniofacial region and is crucial for midfacial skeletogenesis.

Acceleration of diabetes development in CXC chemokine receptor 3 (CXCR3)-deficient NOD mice

AIMS/HYPOTHESIS

The aim of this study was to understand the role of CXC chemokine receptor 3 (CXCR3), a T-helper 1(Th1) type chemokine receptor, in the pathogenesis of type 1 diabetes.

METHODS

We observed the incidence of diabetes in Cxcr3 homozygous knockout mice. We compared the expression pattern of various cytokines and chemokines and the frequency of FOXP3(+) cells in the pancreas and pancreatic lymph nodes from Cxcr3 ( -/- ) NOD mice and wild-type NOD mice. In addition, we observed the migration ability of CXCR3(+)CD4(+) cells to pancreatic islets upon adoptive transfer. Finally, we examined whether Cxcr3 (+) regulatory T cells (Tregs) actually suppressed the onset of diabetes in vivo.

RESULTS

Cxcr3 ( -/- ) NOD mice developed spontaneous diabetes earlier than did wild-type NOD mice. In Cxcr3 ( -/- ) NOD mice, Tregs were more frequent in pancreatic lymph nodes and less frequent in pancreatic islets than in wild-type NOD mice. While transferred CXCR3(-)CD4(+) cells from wild-type NOD mice did not infiltrate pancreatic islets of NOD-severe combined immunodeficiency (SCID) mice, CXCR3(+)CD4(+) cells from the same mice migrated into the recipient islets and contained Forkhead box P3 (FOXP3) upon adoptive transfer. Moreover, CD4(+)CD25(+) cells from wild-type NOD mice suppressed and delayed the onset of diabetes compared with those from Cxcr3 ( -/- ) NOD mice in a cyclophosphamide-induced diabetes model system.

CONCLUSIONS/INTERPRETATION

The mechanism of accelerated diabetes onset in Cxcr3 ( -/- ) NOD mice was considered to be due to the lack of hybrid Tregs (CXCR3(+)FOXP3(+)CD4(+) cells), which could effectively migrate into and regulate Th1 inflammation in local lesions under Cxcr3 knockout conditions.

Relationships between exploratory eye movement dysfunction and clinical symptoms in schizophrenia

AIM

Many psychophysiological tests have been widely researched in the search for a biological marker of schizophrenia. The exploratory eye movement (EEM) test involves the monitoring of eye movements while subjects freely view geometric figures. Suzuki et al. (2009) performed discriminant analysis between schizophrenia and non-schizophrenia subjects using EEM test data; consequently, clinically diagnosed schizophrenia patients were identified as having schizophrenia with high probability (73.3%). The aim of the present study was to investigate the characteristics of schizophrenia patients who were identified as having schizophrenia on EEM discriminant analysis (SPDSE) or schizophrenia patients who were identified as not having schizophrenia on EEM discriminant analysis (SPDNSE).

METHODS

The data for the 251 schizophrenia subjects used in the previous discriminant-analytic study were analyzed, and the demographic or symptomatic characteristics of SPDSE and SPDNSE were investigated. As for the symptomatic features, a factor analysis of the Brief Psychiatric Rating Scale (BPRS) rating from the schizophrenia subjects was carried out.

RESULTS

Five factors were found for schizophrenia symptoms: excitement/hostility; negative symptoms; depression/anxiety; positive symptoms; and disorganization. SPDSE had significantly higher factor scores for excitement/hostility, negative symptoms and disorganization than SPDNSE. Furthermore, the BPRS total score for the SPDSE was significantly higher than that for the SPDNSE.

CONCLUSION

SPDSE may be a disease subtype of schizophrenia with severe symptoms related to excitement/hostility, negative symptoms and disorganization, and EEM parameters may detect this subtype. Therefore, the EEM test may be one of the contributors to the simplification of the heterogeneity of schizophrenia.

Mild retinopathy is a risk factor for cardiovascular mortality in Japanese with and without hypertension: the Ibaraki Prefectural Health Study

BACKGROUND

It is unclear whether mild hypertensive retinopathy is a risk factor for mortality. This study examined whether mild hypertensive retinopathy could be a risk factor for cardiovascular mortality in subjects with and without hypertension.

METHODS AND RESULTS

In this cohort study, 87 890 individuals (29 917 men and 57 973 women) 40 to 79 years of age in 1993 were followed up until 2008. Retinal photography was classified as normal, grade 1, or grade 2 based on the Keith-Wagener-Barker system. Risk ratios for all-cause and cause-specific mortality for each classification were calculated with Cox proportional hazards regression models. Covariates included age, systolic blood pressure, antihypertensive medication use, and other cardiovascular risk factors. Multivariable hazard ratios for total cardiovascular disease mortality were 1.24 (95% confidence interval [CI], 1.12-1.38) and 1.23 (95% CI, 1.03-1.47) for grades 1 and 2 among men and 1.12 (95% CI, 1.01-1.24) and 1.44 (95% CI, 1.24-1.68) for grades 1 and 2 among women, respectively. Hazard ratios for total stroke mortality were 1.31 (95% CI, 1.13-1.53) and 1.38 (95% CI, 1.08-1.77) for grades 1 and 2 among men and 1.30 (95% CI, 1.12-1.50) and 1.70 (95% CI, 1.36-2.11) for grades 1 and 2 among women, respectively. For both hypertensive and normotensive subjects of each sex, multivariable hazard ratios for all-cause mortality, total cardiovascular mortality, and total stroke mortality were significantly higher for grade 1 or 2 compared with normal.

CONCLUSIONS

Mild hypertensive retinopathy is a risk factor for cardiovascular mortality independently of cardiovascular risk factors among men and women with and without hypertension.

Central nervous system drug evaluation using positron emission tomography

In conventional pharmacological research in the field of mental disorders, pharmacological effect and dose have been estimated by ethological approach and in vitro data of affinity to the site of action. In addition, the frequency of administration has been estimated from drug kinetics in blood. However, there is a problem regarding an objective index of drug effects in the living body. Furthermore, the possibility that the concentration of drug in blood does not necessarily reflect the drug kinetics in target organs has been pointed out. Positron emission tomography (PET) techniques have made progress for more than 20 years, and made it possible to measure the distribution and kinetics of small molecule components in living brain. In this article, we focused on rational drug dosing using receptor occupancy and proof-of-concept of drugs in the drug development process using PET.

Functional magnetic resonance imaging study on the effects of acute single administration of paroxetine on motivation-related brain activity

AIM

The aim of the present study was to investigate the effects of acute paroxetine administration on brain activity related to motivation.

METHODS

Sixteen healthy subjects participated in a randomized, single-blind, no-drug/placebo-controlled, cross-over study. After administration of no drug, placebo or paroxetine (selective serotonin reuptake inhibitor; 20 mg), subjects underwent functional magnetic resonance imaging while performing a monetary incentive delay task. We analyzed the differences in brain activities of the reward anticipation/motor preparation period that are subject to motivational modulation. For this purpose, we subdivided the incentive trials on the basis of whether the reaction times (RT) were slower or faster than the subject's mean RT (slow RT and fast RT trials).

RESULTS

No drug and placebo showed robust activation differences in the globus pallidus and putamen for the fast RT trials compared to the slow RT trials, whereas paroxetine showed none. Paroxetine showed significantly lower activations in the globus pallidus, insula, putamen and dorsolateral prefrontal cortex compared to no drug in the fast RT trials.

CONCLUSIONS

Paroxetine single acute administration diminished brain activity induced by motivation in healthy subjects. This may partially explain the increased lack of motivation seen in patients with relatively mild symptoms after taking a dose of paroxetine for the first time.

Potential bioavailability of phosphorus in citrus orchard soil to Microcystis aeruginosa

Algal blooms in eutrophic water bodies are controlled by inputs of phosphorus (P) as the growth-limiting nutrient. Runoff particulate P associated with soil from fields often predominates among P fractions. Here, an algal bioassay to investigate the potential bioavailability of particulate P in soil collected from a citrus orchard was conducted. Microcystis aeruginosa was cultured in medium containing soil as the sole source of P. The P in the soil was not notably solubilized after autoclaving. Analyses of chlorophyll-a, suspended solids, particulate organic carbon, and particulate organic nitrogen showed that M. aeruginosa could utilize some of the P present in the soil, perhaps that in particulate form, but this form of P was not sufficient to maintain optimum growth.