What is an adequate trial with clozapine?: therapeutic drug monitoring and time to response in treatment-refractory schizophrenia

Clozapine is the gold standard and 'last resort' in treatment of refractory schizophrenia. It is important to know whether a trial with clozapine is adequate or not. Six studies show a significantly higher response rate at clozapine plasma trough levels above a therapeutic threshold of 350-400 micro g/L. The absolute risk reduction is about 40%. An additional study found best results with plasma levels between 300 and 700 micro g/L, and one (probably too small) study could not detect a significantly different response rate for 350-450 micro g/L in comparison to 200-300 micro g/L. In addition, two extension studies showed conversion from nonresponders to responders if plasma levels increased above the threshold. Investigations on time to response in treatment with clozapine are often hampered by not controlling for time until plateau of dose titration or clozapine concentration. One of the better studies found 34 responders within 8 weeks after the last dose escalation. The remaining 16 non-responding patients did not change their status during a mean follow-up of 75 weeks. A second 1 year trial found a superior differential response rate for clozapine in comparison to haloperidol only during the first 6 weeks. A third study combined regular clozapine plasma level assays with assessment of response status. At the time of response 17 out of 19 responders showed clozapine concentrations above 350 micro g/L. The nine non-responders remained below this threshold throughout the rest of the year. These results favour an approach of raising the clozapine plasma level in treatment-refractory schizophrenic patients who do not respond to an initial low-to-medium dose treatment with clozapine. Some patients, especially young male smokers, will need dosages higher than 900 mg/day. Addition of low-dose fluvoxamine while closely monitoring clozapine levels can help decrease the high number of necessary pills. An adequate trial with clozapine should last at least 8 weeks on a plasma trough level above 350-400 micro g/L.

Effects of an acute D2-dopaminergic blockade on the somatosensory cortical responses in healthy humans: evidence from evoked magnetic fields

We tested the possible role of dopaminergic activity in the processing of somatosensory afferent information in healthy humans. Somatosensory evoked magnetic fields (SEFs) were recorded in seven subjects in response to left median nerve stimulation. SEFs were obtained in all subjects after oral administration of 2 mg haloperidol, an antagonist to dopaminergic D2 receptors, and placebo, which were given in a randomized, double-blind cross-over design. SEFs were analyzed using a multiple equivalent current dipole (ECD) model, with one dipole at the right primary somatosensory cortex (SI) and at both left and right secondary somatosensory cortices (SII). The earliest responses from SI, peaking at about 20 ms (N20m) and 35 ms (P35m), were not affected by haloperidol. A later deflection peaking at about 75 ms (P60m), however, was slightly reduced (p < 0.05). Responses arising from SII were not significantly changed. The results suggest that dopaminergic activity may be involved in modulating somatosensory processing after the initial stages of cortical activation.

Interplay of electroencephalogram phase and auditory-evoked neural activity

Auditory-evoked potentials (AEPs) were triggered in real time as a function of ongoing electroencephalogram (EEG) phase. Phase triggering on-line or retrospective phase-selective averaging introduces phase artifacts such as spurious troughs or peaks, which mask mid-latency and affect the amplitude of late AEPs. We developed a method to control for phase artifacts by phase-selective averaging of trials, recorded without stimulation, and used this to uncover a previously unknown phase dependency of AEPs. Not only are such findings inconsistent with the standard additive evoked potential model, but we identified clear neural correlates at fixed latencies, which are inconsistent with the recently proposed phase-resetting model. Our findings suggest that a new conceptualization is required to account for the interplay between the correlates of neural-evoked activity and modulation of ongoing EEG that together constitute evoked potentials.

The human frizzled-3 (FZD3) gene on chromosome 8p21, a receptor gene for Wnt ligands, is associated with the susceptibility to schizophrenia

Neurodevelopmental abnormalities have been reported in studies on the pathogenesis of schizophrenia. The Wnt-signaling pathway has been implicated in a variety of processes in neurodevelopment, and the frizzled proteins have been identified as receptors for Wnt ligands. Of the frizzled proteins, frizzled-3 (FZD3) is required for formation of the neural crest and for development of major fiber tracts in the CNS. The human FZD3 gene is located on chromosome 8p21, a positive linkage locus for schizophrenia. We analyzed polymorphisms of the FZD3 gene in patients with schizophrenia and control subjects in the Japanese population. We found a significant association between schizophrenia and the FZD3 gene in single nucleotide polymorphisms and haplotype analyses. Our data suggest that dysregulation of the Wnt-signaling pathway may be involved in the susceptibility to schizophrenia.

From chlorpromazine to clozapine--antipsychotic adverse effects and the clinician's dilemma

The pharmacotherapy of schizophrenia remains an ongoing challenge for researchers and clinicians alike. Current medications remain suboptimal to effectively treat this illness despite the recent surge of what are considered to be better antipsychotics: the atypicals. The atypicals cause fewer extrapyramidal symptoms and tardive dyskinesia, but there is growing concern regarding the significant long-term metabolic and cardiac adverse effects of these novel antipsychotics. There are differences among the atypicals in their propensity to produce these adverse effects, and clinicians should weigh the risk-benefit ratio for each drug with each individual patient. Diabetes, heart disease, obesity, and unhealthy lifestyle choices are on the rise in the general population, and individuals with chronic schizophrenia are even more at risk. The dilemma clinicians face in trying to avoid the neurological morbidity of the typicals (extrapyramidal side effects and tardive dyskinesia) is the risk of consequently exposing patients to both the morbidity and potential mortality of the atypicals (cardiovascular, endocrine, and metabolic adverse effects). The importance of baseline investigations and monitoring at regular intervals as well as identification of patients at risk for obesity, diabetes, and cardiovascular morbidity has become crucial. Informed decision making is essential for successful antipsychotic pharmacotherapy. For a condition, which often necessitates long-term pharmacotherapy, the importance of prevention and (or) minimization of morbidity and mortality related to adverse effects of such pharmacotherapy cannot be understated.

From membrane phospholipid defects to altered neurotransmission: is arachidonic acid a nexus in the pathophysiology of schizophrenia?

Schizophrenia (SZ) is a devastating neuropsychiatric disorder affecting 1% of the general population, and is characterized by symptoms such as delusions, hallucinations, and blunted affect. While many ideas regarding SZ pathogenesis have been put forth, the majority of research has focused on neurotransmitter function, particularly in relation to altered dopamine activity. However, treatments based on this paradigm have met with only modest success, and current medications fail to alleviate symptoms in 30-60% of patients. An alternative idea postulated a quarter of a century ago by Feldberg (Psychol. Med. 6 (1976) 359) and Horrobin (Lancet 1 (1977) 936) involves the theory that SZ is associated in part with phospholipid/fatty acid abnormalities. Since then, it has been repeatedly shown that in both central and peripheral tissue, SZ patients demonstrate increased phospholipid breakdown and decreased levels of various polyunsaturated fatty acids (PUFAs), particularly arachidonic acid (AA). Given the diverse physiological function of membrane phospholipids and PUFAs, an elucidation of their role in SZ pathophysiology may provide novel strategies in the treatment of this disorder. The purpose of this review is to summarize the relevant data on membrane phospholipid/PUFA defects in SZ, the physiological consequence of altered AA signaling, and how they relate to the neurobiological manifestations of SZ and therapeutic outcome.

Diet, smoking and cardiovascular risk in people with schizophrenia: descriptive study

BACKGROUND

Physical health of people with schizophrenia is poor and they die early from cardiovascular disease.

AIMS

To describe the lifestyle of people with schizophrenia through diet, smoking habits, weight and exercise, and to report risk of coronary heart disease (CHD).

METHOD

Dietary habits of 102 community-dwelling people with schizophrenia were assessed by the Scottish Health Survey Questionnaire. Also assessed were smoking habits, physical activity, biochemical indices of nutrition and future risk of CHD.

RESULTS

Fewer males, compared with the general population, reached acceptable levels for consumption of fruit, vegetables, milk, potatoes and pulses. Fewer females reached the levels for consumption of milk and potatoes. Mean number of fruit and vegetable portions consumed per week was 16 (s.d.=14); 71 (70%) were smokers; 25 (86%) females and 50 (70%) males were over weight or obese; 59 (59%) considered themselves physically active; 46 (53%) had a raised cholesterol: high-density lipoprotein ratio, and 64 (74%) a low alpha-tocopherol: cholesterol ratio. Mean 10-year risk of CHD in males was 10.5% (s.d.=8) and in females 7% (s.d.=6).

CONCLUSIONS

The lifestyle of people with schizophrenia must give cause for concern in relation to CHD. Care from concern in relation to secondary care services must address physical as well as mental health.

Cortical and subcortical distribution of middle and long latency auditory and visual evoked potentials in a cognitive (CNV) paradigm

OBJECTIVE

This study concerned sensory processing (post-stimulus late evoked potential components) in different parts of the human brain as related to a motor task (hand movement) in a cognitive paradigm (Contingent Negative Variation). The focus of the study was on the time and space distribution of middle and late post-stimulus evoked potential (EP) components, and on the processing of sensory information in the subcortical-cortical networks.

METHODS

Stereoelectroencephalography (SEEG) recordings of the contingent negative variation (CNV) in an audio-visual paradigm with a motor task were taken from 30 patients (27 patients with drug-resistant epilepsy; 3 patients with chronic thalamic pain). The intracerebral recordings were taken from 337 cortical sites (primary sensorimotor area (SM1); supplementary motor area (SMA); the cingulate gyrus; the orbitofrontal, premotor and dorsolateral prefrontal cortices; the temporal cortex, including the amygdalohippocampal complex; the parietooccipital lobes; and the insula) and from subcortical structures (the basal ganglia and the posterior thalamus). The concurrent scalp recordings were obtained from 3 patients in the thalamic group. In 4 patients in the epilepsy group, scalp recordings were taken separately from the SEEG procedure. The middle and long latency evoked potentials following an auditory warning (S1) and a visual imperative (S2) stimuli were analyzed. The occurrences of EPs were studied in two time windows (200-300 ms; and over 300 ms) following S1 and S2.

RESULTS

Following S1, a high frequency of EP with latencies over 200 ms was observed in the primary sensorimotor area, the supplementary motor area, the premotor cortex, the orbitofrontal cortex, the cingulate gyrus, some parts of the temporal lobe, the basal ganglia, the insula, and the posterior thalamus. Following S2, a high frequency of EP in both of the time windows over 200 ms was observed in the SM1, the SMA, the premotor and dorsolateral prefrontal cortex, the orbitofrontal cortex, the cingulate gyrus, the basal ganglia, the posterior thalamus, and in some parts of the temporal cortex. The concurrent scalp recordings in the thalamic group of patients twice revealed potentials peaking approximately at 215 ms following S1. Following S2, EP occurred with latencies of 215 and 310 ms, respectively. Following S1, separate scalp recordings in 4 patients in the epilepsy group displayed EP 3 times in the 'over 300 ms' time window. Following S2, EP were presented once in the '200-300 ms' time window and 3 times in the 'over 300 ms' time window.

CONCLUSIONS

The SM1, the SMA, multiple sites of the frontal lobe, some parts of the temporal lobe, the cingulate gyrus, the basal ganglia, the insula, and the posterior thalamus all participate in a cortico-subcortical network that is important for the parallel cognitive processing of sensory information in a movement related task.

Case managers' attitudes to the physical health of their patients

OBJECTIVE

To examine the attitudes and practices of case managers working in Area Mental Health Services (AMHS) towards the physical health of people with chronic mental illness.

METHOD

Case managers at four AMHS in Melbourne participated in focus groups and completed a survey questionnaire.

RESULTS

Case managers generally believed that mental illness, psychotropic medication and lifestyle factors contributed to the poor physical health status of their patients. Although many case managers attempted interventions aimed at improving physical health, there was inconsistency regarding the areas targeted. Preventive health measures were often neglected. Overall, there was a sense of pessimism around whether improved physical health was possible for people with chronic mental illness.

CONCLUSIONS

Lack of coordination among health professionals and the health system may contribute to the poor general health of people with mental illness. Patients often have difficulty accessing general practitioners and the culture within the AMHS can exclude considerations of physical health. Case management should include aspects addressing the physical health issues of AMHS clients.

Cognitive functioning and employment in severe mental illness

This study compared cognitive functioning and symptomatology of unemployed, supported employed, and independently employed clients with severe mental illness. Unemployed clients who wanted to work (N = 21) were compared with clients working in supported employment programs (N = 17) and clients who had been working independently for at least 1 year (N = 23) on a neuropsychological battery and the Positive and Negative Syndrome Scale. Clients who were unemployed had more severe symptoms and worse cognitive functioning on both positive and negative symptoms, and almost all domains of cognitive functioning. Supported employed clients had more severe psychotic symptoms and worse working memory than independently employed clients, but did not differ in negative symptoms or the other domains of cognitive functioning, including attention/concentration, psychomotor speed, verbal learning and memory, or executive functions. Finally, job complexity was correlated with impaired executive functions among clients working independently, but not in supported employment. Severe symptoms and cognitive impairment may interfere with the ability of some clients with severe mental illness to obtain competitive work. Supported employment programs appear to work by helping clients compensate for problematic symptoms and cognitive impairment and, to a lesser extent, by finding or developing environmental niches in which these impairments do not impede their ability to perform the necessary job tasks.

Dementia rating and nicotinic receptor expression in the prefrontal cortex in schizophrenia

BACKGROUND

The etiology of dementia that occurs in patients with schizophrenia is not well understood. Nicotinic acetylcholine receptors have been implicated in cognitive function, and deficits in these receptors have been reported in schizophrenia.

METHODS

The present study investigates possible associations of nicotinic receptor subunit expression in the dorsal lateral prefrontal cortex, an area known to be affected in schizophrenia, and dementia rating.

RESULTS

alpha7 immunoreactivity was reduced by 20% to 28% and [(3)H]epibatidine binding was increased twofold in groups of patients with schizophrenia compared to normal control subjects matched for age, postmortem delay, and low levels of brain nicotine and cotinine. In contrast, no significant differences in alpha4, alpha3, or beta2 immunoreactivity or alpha7 messenger RNA expression were observed in schizophrenia patients compared with control subject values. Clinical dementia ratings in patients with schizophrenia were correlated with neither [(3)H]epibatidine binding nor nicotinic receptor subunit expression.

CONCLUSIONS

These data indicate no relationship between the trend for reduced neocortical alpha7 subunit protein expression in schizophrenia and dementia. Further investigations are required to establish whether the reduction in alpha7 protein in the dorsal lateral prefrontal cortex is associated with clinical features other than dementia in schizophrenia.

Pathophysiology of Tourette's syndrome: striatal pathways revisited

Stereotypic behaviors and thoughts are manifested in a range of neuropsychiatric disorders including Tourette's syndrome. To understand and to treat these pathologic stereotypies it is important to establish the molecular, pharmacological and systems-level alterations in brain circuits that accompany such behaviors. We review here experiments performed in rodents and primates that focus on neural concomitants of stereotypies induced by dopaminergic treatments. These studies emphasize the functional importance of the compartmental organization of the striatum and raise the possibility that differential activation of striosomes is related to the severity of the expressed stereotypies and sensitized responses.

Omega-3 and omega-6 fatty acid concentrations in red blood cell membranes relate to schizotypal traits in healthy adults

Reduced omega-3 and omega-6 fatty acids in red blood cell (RBC) membranes are often found in patients with schizophrenia. Here we investigated whether membrane concentrations of these fatty acids might vary as a function of schizotypal traits in non-psychotic individuals. Twenty-five healthy adults completed the O-LIFE schizotypal trait inventory and fatty acid composition of their venous blood samples was analysed via gas-liquid chromatography. Correlations between schizotypy measures and RBC fatty acids were examined and comparisons made between groups high and low on fatty acid measures and schizotypy scores. The omega-6 fatty acids arachidonic, adrenic and docosapentaenoic acid were directly related to positive schizotypal trait measures, as were most omega-3 fatty acids, but none were related to a negative, withdrawn form of schizotypy. Our findings of high RBC concentrations of omega-3 and omega-6 fatty acids in healthy adults with positive schizotypal traits clearly contrast with the low levels often found in schizophrenia, but are quite consistent with evidence that omega-3 fatty acids (notably EPA) can be useful in the treatment of schizophrenic illness.

No contexto da travessia para o ambiente de trabalho: treinamento de habilidades sociais com universitários

Com base nos atuais desafios inerentes à inserção no mercado de trabalho e a crescente valorização da competência para as relações interpessoais nesse contexto, descreve-se um programa de treinamento de habilidades sociais conduzido em um grupo formado por dez universitários em fase final de graduação na área de ciências exatas. O programa, com delineamento A-B-A, teve uma duração de trinta e seis horas, em duas sessões semanais de aproximadamente duas horas cada e foi planejado em módulos teórico e prático, que ocorriam em uma mesma sessão. A avaliação da intervenção foi realizada por meio da aplicação de um inventário tipo auto-relato (IHS-Del-Prette) antes e depois da intervenção e da avaliação por pares ao final do programa. Os resultados indicaram diferenças significativas (teste de Wilcoxon) entre os escores pré e pós-intervenção para a maioria dos participantes e avaliações positivas dos colegas com relação a tais mudanças.

Decreased antioxidant enzymes and membrane essential polyunsaturated fatty acids in schizophrenic and bipolar mood disorder patients

Oxidative stress-mediated cell damage has been considered in the pathophysiology of schizophrenia. Abnormal findings have often been considered related to differences in ethnicity, life style, dietary patterns and medications, all of which influence indices of oxidative stress and oxidative cell damage. To minimize these confounds, schizophrenic patients were compared with age-matched control subjects with the same ethnic background and similar lifestyle, as well as with bipolar mood disorder (BMD) patients. Levels of antioxidant defense enzymes (i.e. superoxide dismutase, SOD; catalase, CAT; and glutathione peroxidase, GPx) were lower in schizophrenic patients than in controls, indicating conditions for increased oxidative stress. The contents of plasma thiobarbituric acid reactive substances (TBARS) were only marginally higher in schizophrenic patients, who had normal levels of arachidonic acid (AA), a major source of TBARS, indicating no significant oxidative membrane lipid peroxidation. Levels of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), however, were significantly lower in schizophrenic patients. When the same indices in BMD patients were compared with findings in matched controls, levels of only SOD and CAT were lower in the patients, whereas GPx was not. Again, as in schizophrenia, the contents of TBARS were marginally higher in BMD patients with no change in levels of AA. Levels of alpha-linolenic acid and EPA were significantly lower and levels of DHA were slightly lower in BMD patients. These data indicate that certain biochemical characteristics may be common to a spectrum of psychiatric disorders, and suggest supplementation of antioxidants and essential fatty acids might affect clinical outcome.

Relationship of Atypical Antipsychotics with Development of Diabetes Mellitus

OBJECTIVE

To review the pharmacoepidemiologic evidence for the link between exposure to atypical antipsychotics and the development of diabetes mellitus.

DATA SOURCES

A MEDLINE search (1990-March 2003) was conducted.

STUDY SELECTION AND DATA EXTRACTION

The search was limited to articles that described findings from analyses of large databases and used the words diabetes or hyperglycemia, and antipsychotic or clozapine or olanzapine or risperidone or quetiapine or ziprasidone or aripiprazole in the title or abstract. The odds ratio or relative risk, together with their corresponding confidence interval, was extracted.

DATA SYNTHESIS

Results are conflicting, and this variability may be due to the different populations studied, different study designs, and the possibility of publication bias related to funding by the pharmaceutical industry. Nevertheless, an increased risk for diabetes mellitus appears to be present for patients receiving atypical antipsychotics. However, differential risk among the atypical antipsychotics is difficult to ascertain.

CONCLUSIONS

Clinicians are urged to manage risk by regularly monitoring all patients receiving atypical antipsychotics for the emergence of diabetes mellitus. Future studies should carefully control for confounding variables such as age, diagnosis, change in weight, activity level, family history, and ethnicity.

Overproduction of neutrophil radical oxygen species correlates with negative symptoms in schizophrenic patients: parallel studies on neutrophil chemotaxis, superoxide production and bactericidal activity

Defective neutrophil function in schizophrenic patients has recently been reported. There are several lines of evidence to support the contribution of oxygen free radicals in schizophrenia, including increased lipid peroxidation, fatty acids and alterations in blood levels of anti-oxidant enzymes. Eighteen schizophrenic patients (DSM-IV) and 15 healthy controls were studied. Neutrophil chemotaxis, superoxide production and bactericidal activity were investigated. A statistically significant increase of superoxide anion release was found in schizophrenic patients compared with controls (mean+/-S.E.M., patients: 6.89+/-0.30 nmol O2-/10(6) cells/min, controls: 5.13+/-0.55 nmol O2-/10(6) cells/min). Moreover, a significant positive correlation between superoxide production and negative symptoms as assessed by the Positive and Negative Syndrome Scale was demonstrated. No differences were detected in chemotaxis and phagocytosis between schizophrenic patients and healthy controls. The present findings of a positive correlation between superoxide generation and negative symptoms in schizophrenic patients support the hypothesis that superoxide anion may participate in the pathogenesis of schizophrenia, as an excess of free radicals could contribute to the deterioration phase of the disease. Further studies are required to establish the role of oxidative stress in the ethiopathogenesis of schizophrenia.

Evidence-based practices: setting the context and responding to concerns

After nearly 20 years of progress in general medicine, the evidence-based practice movement is becoming the central theme for mental health care reform in the first decade of 2000. Several leaders in the movement met to discuss concerns raised by six stakeholder groups: consumers, family members, practitioners, administrators, policy makers, and researchers. Recurrent themes relate to concerns regarding the limits of science, diversion of funding from valued practices, increased costs, feasibility, prior investments in other practices, and shifts in power and control. The authors recommend that all stakeholder groups be involved in further dialog and planning to ensure that practices emerge that represent the integration of the best research evidence with clinical expertise and consumer values.

Automatic activation of the semantic network in schizophrenia: evidence from event-related brain potentials

BACKGROUND

Language disorder associated with schizophrenia might be due to disturbances in both automatic activation and mechanisms of controlled attention. The contribution of each process to semantic memory dysfunction has not been determined for schizophrenia, and the semantic priming paradigm is well-suited for addressing this question. In the present report, event-related potentials (ERPs) elicited under conditions assumed to reveal automatic activation (short prime-target interval and low proportion of related words) are compared directly with ERPs elicited under conditions associated with controlled processing (long prime-target interval and high proportion of related words).

METHODS

Visual ERPs were recorded during a lexical decision task, in which semantic relationship (associated and unassociated words), expectancy (relatedness proportions), and prime-target interval (250- and 850-msec inter-stimulus intervals [ISIs]) were varied. Diagnosis and expectancy were between-subjects factors; semantic relationship and ISI were repeated measures. The N400 priming effect (enhanced negativity to unassociated words) was compared between 34 male normal control subjects tested once and 37 male schizophrenia inpatients evaluated during their participation in a double-blind haloperidol maintenance therapy and placebo replacement protocol.

RESULTS

The N400 priming effect for patients was significantly reduced during both pharmacologic phases, compared with controls. During haloperidol treatment, however, patients showed a significant N400 priming effect over the anterior scalp region and additionally under the automatic activation condition. The N400 priming effect was enhanced under the controlled processing condition for control subjects; this effect was not observed for patients. N400 amplitude elicited under the rapid presentation rate (250-msec ISI) differed between medicated patients and controls; groups did not differ for the 850-msec ISI.

CONCLUSIONS

Findings suggest that automatic activation and mechanisms of controlled attention are both disrupted during semantic memory access for schizophrenia patients. Pharmacologic agents, such as haloperidol, might enhance automatic activation of the semantic network in this patient population, as indexed by the N400 component of the ERP.

Psychosis in elderly patients: classification and pharmacotherapy

Psychosis in elderly patients is a growing clinical concern because psychotic symptoms most frequently occur as noncognitive manifestations of Alzheimer's disease, as side effects of drug therapy for Parkinson's disease, or as the primary abnormalities in schizophrenia, and the clinical characteristics of psychosis are distinct for each. In planning antipsychotic pharmacotherapy for elderly patients, age-related pharmacokinetic changes, polypharmacy for comorbid diseases, and concerns about the underlying conditions responsible for the psychotic symptoms must be considered. Traditional antipsychotic agents bind to dopamine receptors and effectively relieve positive schizophrenic symptoms but frequently cause tardive dyskinesia and other extrapyramidal symptoms, a problem for elderly patients, particularly for those with Parkinson's disease. Atypical antipsychotics bind to dopamine and serotonin receptors, relieving both positive and negative symptoms, and are less likely to cause extrapyramidal symptoms. The authors review common diagnostics associated with psychosis in the elderly and clinical guidelines to selecting antipsychotic pharmacotherapy.

Neurophysiology of Tourette's syndrome: pathophysiological considerations

At present the neurophysiology of Tourette's syndrome (TS) has been investigated largely from two perspectives; one for evaluation of the dysfunction of the cerebral cortex and the other for clarification of the neuronal mechanisms that underlie tics and related symptoms. For the former the following examinations have been conducted: quantitative analyses of scalp electroencephalography (EEG), premovement EEG potentials, contingent negative variation, transcranial magnetic stimulation, and neuroimaging studies, including echo-planar images and positron emission tomography scans. These explorations have revealed the likely involvement of the subcortical and the cortical structures, particularly of the basal ganglia, in the pathophysiology of TS. For the latter, surface electromyography, evoked potentials, saccadic eye movements, and polysomnographies have been performed, and again have suggested a dysfunction of the basal ganglia and the brainstem neurons in TS patients. These neurophysiological studies suggest dysfunction of both motor and non-motor basal ganglia-thalamocortical circuitries in TS patients, which is hypothesized to be caused by hypofunction of the dopamine (DA) neurons associated with DA receptor supersensitivity, a well as hypofunction of the serotonergic neurons of the brainstem. Polysomnographical examination suggests that the dysfunction of the nigrostriatal (NS)-DA neurons is not a progressive process, but that the dysfunction is closely associated with an early occurrence of the developmental decrement of the activities of the NS-DA system to mature in a normal fashion. The associated DA receptor supersensitivity is assumed to be a consequence of this developmental abnormality and not due to denervation supersensitivity.

Strategies for leading the implementation of evidence-based practices

Many mental health authority and program administrators would like to implement behavioral health practices that have been demonstrated to be effective. Leading practice implementation involves promoting behavior change in health care providers. Reviews of the general medical literature on practice change conclude that education alone has little impact on practitioner behavior and that intensive, multifaceted interventions that attend to local circumstances have the greatest likelihood of affecting change. This article briefly reviews the literature on health care practice change and offers some strategy suggestions for administrators who are leading evidence-based practice implementation initiatives.

Chromosome aberrations in a schizophrenia population

Cytogenetic abnormalities with schizophrenia may provide a valuable clue to the identification of target loci and successful search for major genes. We have performed chromosomal examinations by using the GTG banding technique on 134 schizophrenics. In 43 patients (32%), random numerical and structural aberrations were detected. Structural aberrations predominated and usually consisted of deletions and inversion of various chromosomes. Numerical changes were present in one or two cells in 14 cases including trizomy 21, marker and acentric chromosomes, and 47,XXY. The seven cases with pericentric inversion and enlargement of the heterochromatin region of chromosome 9 (inv(9); 9qh+) were observed in the study. The incidence (5.2%) of inv(9) and 9qh+ in our schizophrenic patients were found higher than the general population, suggesting that a susceptibility locus for schizophrenia may be located at pericentromeric region of chromosome 9. Our study have detected 1q21, 7q23, inv(9), 9qh+, 11q23, 21q22, 22q11-13 and Xp11-q13 suggested that these chromosomal lesions are prevalent in schizophrenics. The reason for this might be that these anomalies increase risk for schizophrenia in a relatively nonspecific way, such as contributing to disruption of normal embryogenesis of the nervous system.

Eicosapentaenoic acid in the treatment of schizophrenia and depression: rationale and preliminary double-blind clinical trial results

It has been hypothesised that polyunsaturated fatty acids (PUFA) play an important role in the aetiology of schizophrenia and depression. Evidence supporting this hypothesis for schizophrenia includes abnormal brain phospholipid turnover shown by 31P Magnetic Resonance Spectroscopy, increased levels of phospholipase A2, reduced niacin skin flush response, abnormal electroretinogram, and reduced cell membrane levels of n-3 and n-6 PUFA. In depression, there is strong epidemiological evidence that fish consumption reduces risk of becoming depressed and evidence that cell membrane levels of n-3 PUFA are reduced. Four out of five placebo-controlled double- blind trials of eicosapentaenoic acid (EPA) in the treatment of schizophrenia have given positive findings. In depression, two placebo-controlled trials have shown a strong therapeutic effect of ethyl-EPA added to existing medication. The mode of action of EPA is currently not known, but recent evidence suggests that arachidonic acid (AA) if of particular importance in schizophrenia and that clinical improvement in schizophrenic patients using EPA treatment correlates with changes in AA.

Can recovery-focused multimodal psychotherapy facilitate symptom and function improvement in people with treatment-resistant psychotic illness? A comparison study

OBJECTIVE

To assess whether recovery-focused multimodal psychotherapy can facilitate symptom and function improvement in people with treatment-resistant psychotic illness.

METHOD

Nine people with treatment-resistant schizophrenia or schizoaffective disorder whose symptoms and level of functioning necessitated inpatient care were engaged in individual multimodal psychotherapy for up to 21 months. In addition to the multimodal therapy they also received standard inpatient care. Twelve people retrospectively matched for diagnosis, age, sex, and chronicity of illness, formed a comparison group. They also received standard inpatient care. The standard inpatient care for both experimental and comparative groups consisted of custodial care, predominantly atypical antipsychotic drug therapy, and ongoing care from a key worker.

RESULTS

The treatment group showed clinically significant improvements in the overall Positive and Negative Symptom Scale (PANSS) scores which was significantly better than the changes found in the comparison group (p = 0.037). There was a 43% reduction in positive symptoms, a 30% reduction in negative symptoms, a 27.5% reduction in general psychopathology symptoms and a 30% reduction in overall scores on the PANSS. General behaviour scores on the Rehabilitation Evaluation of Hall and Baker were clinically improved, with a 32% reduction, as were deviant scores, with a 93.3% reduction. The change in the deviant scores was significantly better in the treatment group (p = 0.025).

CONCLUSION

Recovery-focused multimodal psychotherapy may facilitate symptom and function improvement in people with treatment-resistant psychotic illness.

Effects of procyclidine on eye movements in schizophrenia

Smooth pursuit eye movement (SPEM) and antisaccade deficits are observed in the schizophrenia spectrum and have been used to study the pathophysiology as well as the genetic basis of this condition. The neurotransmitter acetylcholine has been implicated in a number of cognitive processes thought to underlie SPEM and antisaccade performance. This study investigates effects on eye movements of procyclidine, an anticholinergic drug often administered to schizophrenic patients. A total of 13 patients completed a double-blind placebo-controlled crossover design, receiving 15 mg procyclidine and placebo. Seven participants received procyclidine first and placebo second, six participants were tested in the reverse order. SPEM and antisaccade (as well as fixation and prosaccade) eye movements were recorded using infrared oculography. Results showed that procyclidine overall, relative to placebo, mildly worsened SPEM performance, as indicated by nonsignificantly reduced gain (p=0.08) and increased frequency of intrusive anticipatory saccades during pursuit (p=0.06). A significant interaction of group and order of administration indicated that procyclidine increased the rate of antisaccade reflexive errors only when administered first; the opposite pattern was observed when placebo was administered first, likely due to the operation of practice effects at second assessment. These findings indicate that acute administration of a clinically relevant dose of procyclidine leads to mild impairments in eye movement performance in schizophrenic patients, suggesting the need to consider this compound in oculomotor studies in schizophrenia. The action of this anticholinergic drug on oculomotor performance is consistent with the hypothesized role of the cholinergic system in the cognitive mechanisms of attention and working memory, processes thought to underlie SPEM and antisaccade performance. Effects of order of administration and practice on the antisaccade task suggest that these factors need to be taken into consideration in future pharmacological studies.

Development of disease-specific quality of life measurement tools

Most of the conditions that physicians treat each day impact a patient's quality of life rather than the length or quantity of life. In orthopaedic surgery, traditional objective measures of patient outcome have included range of motion, strength, or radiographic variables. Although these measures have gained wide acceptance through their long-standing use, they are usually very poor indicators of the functional and psychological aspects of health. It makes sense to measure the phenomenon of health-related quality of life when assessing the relative efficacies of treatments that are available. If we can accept that health-related quality of life is important to measure, the next steps are to understand the types of instruments that are available and the appropriate methods by which these instruments should be developed and tested. Instruments fall into 2 general categories: generic or specific, each with specific advantages and disadvantages. The methodology for the development of quality of life tools emphasizes patient input and feedback. Determination of validity, reliability, and responsiveness in patients similar to those who will participate in trials is an important part of establishing the usefulness of an instrument.

Reduced laterality of the source locations for generators of the auditory steady-state field in schizophrenia

BACKGROUND

Reduced hemispheric asymmetry of evoked field generators in schizophrenia in secondary auditory cortex has been replicated with mixed success. This disparity is possibly due to the complex nature of the 100-msec generators typically investigated. In this study, we evaluated a source located in primary auditory cortex, responsible for the steady-state response, to determine whether similar asymmetries were present.

METHODS

Contralateral evoked fields were recorded with a 37-channel neuromagnetometer in response to 40-Hz pulse trains. Dipole models were used to localize the sources in both hemispheres of schizophrenic subjects (n = 17) and normal control subjects (n = 18).

RESULTS

Control subjects were asymmetrically lateralized, with sources in the right hemisphere approximately 6 mm further anterior than those on the left. In contrast, schizophrenic subjects showed no significant difference between hemispheres.

CONCLUSIONS

The findings support theories linking schizophrenia to disturbed asymmetry of temporal lobe function. The steady-state response, having a more discrete Heschl's gyrus generator location, may be better suited for evaluating auditory asymmetry.

Fundamental principles of evidence-based medicine applied to mental health care

This article discusses the fundamental principles of evidence-based medicine: using the best available evidence, individualizing the evidence, attending to patient preferences, and expanding clinical expertise. These principles have important implications for the adoption of evidence-based practices in mental health care.

SSR181507, a dopamine D(2) receptor antagonist and 5-HT(1A) receptor agonist. I: Neurochemical and electrophysiological profile

SSR181507 ((3-exo)-8-benzoyl-N-[[(2S)7-chloro-2,3-dihydro-1,4-benzodioxin-1-yl]methyl]-8-azabicyclo[3.2.1]octane-3-methanamine monohydrochloride) is a novel tropanemethanamine benzodioxane derivative that possesses high and selective affinities for D2-like and 5-HT(1A) receptors (K(I)=0.8, 0.2, and 0.2 nM for human D(2), D(3), and 5-HT(1A), respectively). In vivo, SSR181507 inhibited [(3)H]raclopride binding to D(2) receptors in the rat (ID(50)=0.9 and 1 mg/kg, i.p. in limbic system and striatum, respectively). It displayed D(2) antagonist and 5-HT(1A) agonist properties in the same concentration range in vitro (IC(50)=5.3 nM and EC(50)=2.3 nM, respectively, in the GTPgammaS model) and in the same dose range in vivo (ED(50)=1.6 and 0.7 mg/kg, i.p. on striatal DA and 5-HT synthesis, respectively, and 0.03-0.3 mg/kg, i.v. on dorsal raphe nucleus firing rate). It selectively enhanced Fos immunoreactivity in mesocorticolimbic areas as compared to the striatum. This regional selectivity was confirmed in electrophysiological studies where SSR181507, given acutely (0.1-3 mg/kg, i.p.) or chronically (3 mg/kg, i.p., o.d., 22 days), increased or decreased, respectively, the number of spontaneous active DA cells in the ventral tegmental area, but not in the substantia nigra. Moreover, SSR181507 increased both basal and phasic DA efflux (as assessed by microdialysis and electrochemistry) in the medial prefrontal cortex and nucleus accumbens, but not in the striatum. This study shows that the combination of D(2) receptor antagonism and 5-HT(1A) agonism, in the same dose range, confers on SSR181507 a unique neurochemical and electrophysiological profile and suggests the potential of this compound for the treatment of the main dimensions of schizophrenia.

Patients’ opinion on what constitutes good psychiatric care

The present study investigates patients' opinion on what constitutes good psychiatric care. It was a qualitative study using an open-ended in-depth interview centering on the patient's experiences of receiving psychiatric care. The subjects were selected to ensure maximum variation and heterogeneity. A model of deliberate sampling for heterogeneity and a modified, stratified sampling method were used. One outpatient and one inpatient sample were selected. The description and analysis of data were based on a variable-oriented, cross-case technique. The analysis was made separately for the two sub-samples. The main result for both samples was the emergence of one main category: the quality of the helping encounter. The quality of the relationship between patient and therapist/staff, and being understood by the therapist/staff, formed the most central aspects of good care. For the inpatient group the analyses also pointed to stability and structure and relief of pressure as main categories. Though the focus of the study was on satisfaction with general psychiatric care, the results revealed a construct initially identified within the field of psychotherapy, namely the 'helping alliance', as the most crucial factor. The results also gave some further indications of what bring about a good therapeutic relationship; and prominent in this study, and not very often reported in the context of helping alliance, was that ambivalence, time and meaning were important constituents of the relationship. The findings emphasize the importance and quality of the therapeutic relationship and point to the incorporation of psychotherapeutic principles in all provider-patient relationships in general psychiatric care.

The amygdala and schizophrenia: a volumetric magnetic resonance imaging study in first-episode, neuroleptic-naive patients

BACKGROUND

The attempts to evaluate amygdaloid volumes using magnetic resonance imaging (MRI) in patients with schizophrenia have yielded highly divergent results.

METHODS

Volumes of the amygdala were measured in 22 healthy participants and 18 neuroleptic-naive patients with first-episode schizophrenia, while controlling for intracranial area, gender, age, and handedness.

RESULTS

Persons with schizophrenia presented significantly lower amygdaloid volumes bilaterally. No significant correlations were found between the amygdaloid volumes and either the duration of the disease or the symptom severity.

CONCLUSIONS

Amygdaloid volume anomalies are already present in the early phases of schizophrenia.

Dopamine transporter change in drug-naive schizophrenia: an imaging study with 99mTc-TRODAT-1

The aim of this study was to use a specific dopamine transporter (DAT) ligand, 99mTc-TRODAT-1 with single photon emission computed tomography (SPECT) to investigate the densities of DAT in the striatal dopaminergic system in patients with schizophrenia. Striatal DAT uptakes were measured in 12 drug-nai;ve schizophrenic patients and 12 age- and sex-matched healthy volunteers. The psychometric tools included the Standardized Clinical Assessment for Neuropsychiatry (SCAN) and the Positive and Negative Syndrome Scale (PANSS). Semiquantitative analyses using the ratio of uptake in caudate, putamen, and striatum to occipital lobe, and left-right asymmetry were performed. Decreased TRODAT uptake in the right striatum and increased uptake in the left striatum were found in the schizophrenics. However, there is no overall difference in the average striatum uptake. The right-left asymmetry of the caudate and putamen DAT binding seen in the healthy control group disappeared in the schizophrenia group. The decreased right uptake and increased left uptake in the striatum might lead to the lack of right-left asymmetry in neuroleptic-nai;ve schizophrenia patients, confirming that the disorder could be due to a disruption in brain lateralization. This is the first report on the use TRODAT to evaluate the DAT density in schizophrenia patients and shows lack of asymmetry in striatal uptake of TRODAT in schizophrenics. The findings also suggest that TRODAT SPECT may be a useful technique to measure dopamine transmission in the human brain and for understanding the pathophysiology of neuropsychiatric disorders.

The relationship between membrane pathology and language disorder in schizophrenia

Receptive language disorder in schizophrenia has been hypothesized to involve a fundamental deficit in the temporal (time-based) dynamics of brain function that includes disruptions to patterns of activation and synchronization. In this paper, candidate mechanisms and pathways that could account for this basic deficit are discussed. Parallels are identified between the patterns of language dysfunction observed for schizophrenia and dyslexia, two separate clinical disorders that may share a common abnormality in cell membrane phospholipids. A heuristic is proposed which details a trajectory involving an interaction of brain fatty acids and second-messenger function that modulates synaptic efficacy, and, in turn, influences language processing in schizophrenia patients. It is additionally hypothesized that a primary deficit of functional excitation originating in the cerebellum, in combination with a compensatory decrease of functional inhibition in the prefrontal cortex, influences receptive language dysfunction in schizophrenia.

Differential role of serotonergic projections arising from the dorsal and median raphe nuclei in locomotor hyperactivity and prepulse inhibition

While an involvement of brain serotonin systems in schizophrenia has been suggested by many studies, the relative role of different serotonergic projections in the brain remains unclear. We therefore examined the effects of selective brain serotonin depletion on psychotropic drug-induced locomotor hyperactivity and prepulse inhibition, two animal models of aspects of schizophrenia. Pentobarbital-anesthetized (60 mg/kg, i.p.) male Sprague-Dawley rats were stereotaxically microinjected with 1 microl of a 5 microg/microl solution of the serotonergic neurotoxin 5,7-dihydroxytryptamine (5,7-DHT) into either the dorsal or median raphe nucleus. At 2 weeks after the surgery, rats with dorsal raphe lesions did not show changes in psychotropic drug-induced locomotor hyperactivity, but displayed partial disruption of prepulse inhibition. In contrast, rats with median raphe lesions showed significant enhancement of phencyclidine-induced, but not amphetamine-induced locomotor hyperactivity and a marked disruption of prepulse inhibition. These results provide evidence for differential involvement of serotonergic projections in locomotor hyperactivity and prepulse inhibition. This study may help to explain the role of different serotonin projections in the brain in the pathophysiology of schizophrenia.

The C270T polymorphism of the brain-derived neurotrophic factor gene is associated with schizophrenia

We investigated a novel polymorphism of single nucleotide substitution (C270T) of the brain-derived neurotrophic factor (BDNF) gene in schizophrenia patients (n=101) and in controls (n=68). The frequency of the C/T genotype and the T allele were significantly higher in the schizophrenia patients (25.7% and 13.9%, respectively) compared with the controls (5.9% and 2.9%). There were no significant differences in Positive and Negative Symptom Scale (PANSS) items and Global Assessment of Functioning (GAF) scores between the patients with C/C and C/T genotypes. Further studies are warranted to elucidate the significance of this finding in the pathophysiology of schizophrenia.

Clozapine treatment attenuated somatic and affective signs of nicotine and amphetamine withdrawal in subsets of rats exhibiting hyposensitivity to the initial effects of clozapine

BACKGROUND

Based on the phenomenologic similarity between symptoms of drug withdrawal and the negative symptoms of schizophrenia (e.g., anhedonia), we hypothesized that treatment with clozapine may be effective against nicotine and amphetamine withdrawal.

METHODS

A rate-independent discrete-trial threshold procedure was used to assess brain stimulation reward in rats prepared with electrodes in the lateral hypothalamus. Somatic signs of nicotine withdrawal were also assessed.

RESULTS

Clozapine administration (.75 or 1.5 mg/kg) during nicotine or amphetamine withdrawal did not affect the threshold elevations associated with drug withdrawal. The.75 mg/kg clozapine dose reversed the increased number of somatic signs of nicotine withdrawal. Ten days of clozapine treatment (3 mg/kg/b.i.d.) before exposure to nicotine prevented the threshold elevations in a subset of rats and the increases in somatic signs in all subjects. Fourteen-day pretreatment with clozapine (6 mg/kg/day) decreased the duration of amphetamine withdrawal.

CONCLUSIONS

Correlational analyses indicated that the ability of clozapine to prevent the affective aspects of drug withdrawal depended on low sensitivity to acute clozapine under baseline conditions. The results are consistent with the clinical situation where clozapine is partially effective against the negative symptoms of schizophrenia and more effective in some individuals than others. These results indicate that lack of sensitivity to the initial negative effects of clozapine may predict its a subsequent therapeutic response. Finally, the data suggest that there may be commonalities in the neurosubstrates mediating affective aspects of drug withdrawal and the negative symptoms of schizophrenia.

Prepulse inhibition deficits of the startle reflex in neonatal ventral hippocampal-lesioned rats: reversal by glycine and a glycine transporter inhibitor

BACKGROUND

Neonatal ventral hippocampal (NVH) lesions in rats induce behavioral abnormalities at adulthood thought to simulate some aspects of the positive, negative, and cognitive deficits classically observed in schizophrenic patients. Such lesions induce a postpubertal emergence of prepulse inhibition (PPI) deficits of the startle reflex reminiscent of the sensorimotor gating deficits observed in a majority of schizophrenic patients. To study the potential involvement of the glycinergic neurotransmission in such deficits, we investigated the capacity of glycine (an obligatory N-methyl-D-aspartate [NMDA] receptor co-agonist) and ORG 24598 (a selective glycine transporter 1 inhibitor) to reverse NVH lesion-induced PPI deficits in rats.

METHODS

Ibotenic acid was injected bilaterally into the ventral hippocampus of 7-day-old pups. Prepulse inhibition of the startle reflex was measured at adulthood.

RESULTS

Glycine (.8 and 1.6 g/kg IP) and ORG 24598 (10 mg/kg IP) fully and partially reversed lesion-induced PPI deficits, respectively.

CONCLUSIONS

These findings confirm that an impaired glutamatergic neurotransmission may be responsible for PPI deficits exhibited by NVH-lesioned rats and support the hypoglutamatergic hypothesis of schizophrenia. They also suggest that drugs acting either directly at the NMDA receptor glycine site or indirectly on the glycine transporter 1 could offer promising targets for the development of novel therapies for schizophrenia.

Membrane polyunsaturated fatty acids and CSF cytokines in patients with schizophrenia

Findings to date provide evidence that altered membrane structure and function are present in patients with either first-episode or chronic schizophrenia, suggesting defects in phospholipid metabolism and cell signaling in schizophrenia. The purpose of this investigation is to test whether decreased membrane polyunsaturated fatty acids (PUFAs) were associated with an increased secretion of proinflammatory cytokines. Thus, we measured interleukin 6 (IL-6) and interleukin 10 (IL-10) in cerebrospinal fluid (CSF) of patients with chronic schizophrenia as well as PUFAs of red blood cell (RBC) membranes from the same individuals. A significant and inverse correlation was found between CSF IL-6 (not IL-10) and RBC membrane PUFAs levels in both haloperidol-treated and medication-free patients with schizophrenia. Specifically, such an association was found in the n-6 (18:2, 20:4, and 22:4) and, to a lesser extent, the n-3 fatty acids. Taken together, the present findings suggest that decreased membrane PUFAs may be related to an immune disturbance in schizophrenia, possibly resulting from an increased phospholipase A2 activity mediated through the proinflammatory cytokines.

Forebrain dopamine systems--can they help us to understand psychosis?

Under normal circumstances, emotional and affective signals within the brain are tempered by signals from higher brain centres, including the forebrain. These control systems ensure that responses to emotional and affective stimuli are appropriate for the environment within which they are generated. In patients with schizophrenia, these control systems are dysfunctional causing the patients to become oversensitive to such emotional stimuli and leading to the exaggerated reactions that are symptomatic of the disease [7,19].

Interpreting abnormality: an EEG and MEG study of P50 and the auditory paired-stimulus paradigm

Interpretation of neurophysiological differences between control and patient groups on the basis of scalp-recorded event-related brain potentials (ERPs), although common and promising, is often complicated in the absence of information on the distinct neural generators contributing to the ERP, particularly information regarding individual differences in the generators. For example, while sensory gating differences frequently observed in patients with schizophrenia in the P50 paired-click gating paradigm are typically interpreted as reflecting group differences in generator source strength, differences in the latency and/or orientation of P50 generators may also account for observed group differences. The present study examined how variability in source strength, amplitude, or orientation affects the P50 component of the scalp-recorded ERP. In Experiment 1, simulations examined the effect of changes in source strength, orientation, or latency in superior temporal gyrus (STG) dipoles on P50 recorded at Cz. In Experiment 2, within- and between-subject variability in left and right M50 STG dipole source strength, latency, and orientation was examined in 19 subjects. Given the frequently reported differences in left and right STG anatomy and function, substantial inter-subject and inter-hemispheric variability in these parameters were expected, with important consequences for how P50 at Cz reflects brain activity from relevant generators. In Experiment 1, simulated P50 responses were computed from hypothetical left- and right-hemisphere STG generators, with latency, amplitude, and orientation of the generators varied systematically. In Experiment 2, electroencephalographic (EEG) and magnetoencephalographic (MEG) data were collected from 19 subjects. Generators were modeled from the MEG data to assess and illustrate the generator variability evaluated parametrically in Experiment 1. In Experiment 1, realistic amounts of variability in generator latency, amplitude, and orientation produced ERPs in which P50 scoring was compromised and interpretation complicated. In Experiment 2, significant within and between subject variability was observed in the left and right hemisphere STG M50 sources. Given the variability in M50 source strength, orientation, and amplitude observed here in nonpatient subjects, future studies should examine whether group differences in P50 gating ratios typically observed for patient vs. control groups are specific to a particular hemisphere, as well as whether the group differences are due to differences in dipole source strength, latency, orientation, or a combination of these parameters. Present analyses focused on P50/M50 merely as an example of the broader need to evaluate scalp phenomena in light of underlying generators. The development and widespread use of EEG/MEG source localization methods will greatly enhance the interpretation and value of EEG/MEG data.