Global economic burden of schizophrenia: a systematic review

Defining the concept of family caregiver burden in patients with schizophrenia: a systematic review protocol

BACKGROUND

Since the deinstitutionalization policy, in psychiatric hospitals, the care of patients with schizophrenia was left to their families which has been imposing a heavy burden on them. Family caregiver burden could have consequences for caregivers, patients, and the society. There is very little consensus on the definition and dimensions of the caregiver burden, which leads to a lack of consistency in the results of research. Thus, the present study was aimed to redefine the family caregiver burden of patients with schizophrenia.

METHODS

The databases PubMed, Scopus, Web of Science, MEDLINE (Via Ovid), ProQuest, SCI, Magiran, SID, and IranDoc will be searched from 1940 to 2018 using subject headings and appropriate terms in both Farsi and English languages. Also, gray literature and the reference list of included articles will be used to offer an appropriate definition of the family caregiver burden in patients with schizophrenia. Two independent reviewers will participate in study selection, data collection, and quality assessment steps. The result will be presented in tabular form, and meta-synthesis will be performed.

DISCUSSION

The result of this systematic review will help present the comprehensive definition of the family caregiver burden in patients with schizophrenia according to its evolutionary trend.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018099372.

Treatment Adherence in Youth with First-Episode Psychosis: Impact of Family Support and Telehealth Delivery

Mental health-care delivery to young people with first-episode schizophrenia presents significant challenges especially in underserved areas. This chart review reveals the importance of family support as a predictor for medication and treatment adherence with this vulnerable group. An unexpected disengagement rate of 47% was discovered. It was further discovered that receiving care with telehealth delivery was a significant predictor of lost to follow-up or treatment nonadherence. Recommendations include psychoeducation for families during the initial crisis, initiation of long-acting injectable antipsychotics early in care, a hybrid telehealth intervention with in-home medication delivery, and collaboration with educational, vocational county agencies for employment support. A system of care must be developed to support young people with this severe illness for optimum outcome and protection of long-term cognitive functioning.

Health state utility values in schizophrenia: protocol for a systematic review and meta-analysis

INTRODUCTION

Cost-effectiveness analyses that use quality-adjusted life-years (QALYs) allow comparing the value for money of interventions across different health problems. Health state utility values (HSUVs) are crucial to calculate QALYs. These are weights attached to a given health state reflecting preferences in health-related quality of life (HRQoL). In schizophrenia, there is extensive evidence about the consequences of this condition on HRQoL. Besides, several interventions have claimed to be cost-effective in terms of QALYs gained. Despite this evidence, a systematic review of HSUVs has not been conducted. Therefore, we aim to synthesise the evidence about HSUVs in schizophrenia.

METHODS AND ANALYSIS

We will conduct a systematic review of the literature about HSUVs in people with schizophrenia following the Preferred Reporting Items for Systematic review and Meta-Analysis and the International Society for Pharmacoeconomics and Outcomes Research task force recommendations. The submissions records of eight electronic peer-reviewed databases and three health technology assessment (HTA) agencies will be searched. Quantitative synthesis will be carried out in comparable studies, using random-effects meta-analysis. Heterogeneity will be explored using meta-regression if more than 10 studies per covariate are found. A narrative synthesis and methodological quality of included studies will be also reported.

DISCUSSION

This review will provide a synthesis of the HSUVs estimated for different states experienced by people with schizophrenia. This will inform analysts when calculating QALYs, using values in a more transparent and accountable manner. Finally, it will shed light on evidence gaps and limitations about this measure in mental health.

PROSPERO REGISTRATION NUMBER

CRD42019123582.

The association between early-onset schizophrenia with employment, income, education, and cohabitation status: nationwide study with 35 years of follow-up

PURPOSE

Individuals with schizophrenia have been reported to have low employment rates. We examined the associations of schizophrenia with employment, income, and status of cohabitation from a work life course perspective.

METHODS

Nationwide cohort study including all individuals (n = 2,390,127) born in Denmark between 1955 and 1991, who were alive at their 25th birthday. Diagnosis of schizophrenia (yes/no) between ages 15 and 25 was used as an exposure. Employment status, annual wage or self-employment earnings, level of education, and cohabitant status from the age of 25-61 (years 1980-2016) were used as outcomes.

RESULTS

Schizophrenia diagnosis between ages 15 and 25 (n = 9448) was associated with higher odds of not being employed (at the age of 30: OR 39.4, 95% CI 36.5-42.6), having no secondary or higher education (7.4, 7.0-7.8), and living alone (7.6, 7.2-8.1). These odds ratios were two-to-three times lower and decreasing over time for those individuals who did not receive treatment in a psychiatric inpatient or outpatient clinic for schizophrenia after the age of 25. Between ages 25-61, individuals with schizophrenia have cumulative earning of $224,000, which is 14% of the amount that the individuals who have not been diagnosed with schizophrenia earn.

CONCLUSIONS

Individuals with schizophrenia are at high risk of being outside the labour market and living alone throughout their entire life, resulting in an enormous societal loss in earnings. Individuals with less chronic course of schizophrenia had a gradual but substantial improvement throughout their work life.

Evaluating the acceptability of a co-produced and co-delivered mental health public engagement festival: Mental Health Matters, Jakarta, Indonesia

BACKGROUND

Public engagement events are an important early strategy in developing a meaningful research agenda, which is more impactful and beneficial to the population. Evidence indicates the potential of such activities to promote mental health literacy. However, this has not yet been explored in Indonesia.

AIM

This paper describes a mental health public engagement festival carried out in Indonesia in November 2018 and uses evaluation data to consider the acceptability and use of such activities in Indonesia in the future.

METHOD

Evaluation data was collected from 324 of the 737 people who attended a six-day mental health festival comprising 18 events including public lectures, film screenings, arts activities, exercise classes and panel discussions. Attendees were asked to evaluate the festival in terms of its quality, benefits and areas for improvement. Descriptive statistics were used to analyse the evaluation data. 87 service users, carers, academics and professionals also engaged in a research prioritisation exercise to collaboratively determine mental health research priorities for Indonesia.

RESULTS

Participants evaluated the festival extremely positively with a significant majority (92%) rating the quality of the festival as good or excellent. Attendees reported an increase in their understanding of mental health issues and identified intended behaviour change including an increased propensity for future engagement with mental health research. Key strengths of the festival included the central role of patients, carers and the local community in the design and delivery of the festival which promoted emotional engagement and development of shared understanding and the use of international experts which in attendees' opinion further enhanced the credibility of festival activities.

CONCLUSION

This manuscript indicates that a co-produced mental health public engagement festival is a potentially acceptable way to increase awareness of mental health in Indonesian populations. Future festivals should be larger in scope and target men, older people and the general public to maximise benefit and incorporate rigorous evaluation of effectiveness.

Comparison of Clinical Characteristics Between the Patients with Schizophrenia on Clozapine Treatment with Those Taking Combination of Long-Acting Injectable and Oral Antipsychotics

INTRODUCTION

The primary aim of this study was to compare clinical characteristics between the patients with schizophrenia on clozapine treatment with those under combination of long-acting injectable and oral antipsychotics (combined treatment), and the secondary aim was to evaluate the impact of obsessive-compulsive disorder (OCD) comorbidity on the clinical variables.

METHODS

The patients with schizophrenia applied at Outpatient Psychiatry Clinic of the University between October 2017 and March 2018 taking clozapine or combined treatment were included in the study. The participants were administered Brief Psychiatric Rating Scale (BPRS), Clinical Global Impressions Scale, Scale for the Assessment of Positive and Negative Symptoms (SAPS/SANS), Calgary Depression Scale for Schizophrenia (CDSS), Yale-Brown Obsessive Compulsive Scale (YBOCS), Turkish version of Schedule for Assessing the three components of insight (SAI), and Global Assessment of Functioning Scale (GAF).

RESULTS

Patients on clozapine had higher Y-BOCS, BPRS, SANS, CDSS scores, and lower GAF scores compared to those taking combined antipsychotics (p<0.05). OCD comorbidity rate was 13% in the combination therapy group and 36% in clozapine users. The SAPS scores were higher but CDSS scores were lower in clozapine users with the presence of OCD comorbidity (p<0.05).

CONCLUSION

Clozapine and combined therapy groups differed widely by the clinical characteristics of the patients in this study. Both groups showed a high OCD comorbidity rate in this study and OCD comorbidity should be considered when schizophrenia treatment is initiated to obtain more satisfactory results. Furthermore, patients on clozapine seem to show a different relationship with OCD comorbidity compared to those under combined treatment.

Cost-Effectiveness Evaluations of Psychological Therapies for Schizophrenia and Bipolar Disorder: A Systematic Review

OBJECTIVES

This review aims to assess the cost-effectiveness of psychological interventions for schizophrenia/bipolar disorder (BD), to determine the robustness of current evidence and identify gaps in the available evidence.

METHODS

Electronic searches (PsycINFO, MEDLINE, Embase) identified economic evaluations relating incremental cost to outcomes in the form of an incremental cost-effectiveness ratio published in English since 2000. Searches were concluded in November 2018. Inclusion criteria were: adults with schizophrenia/BD; any psychological/psychosocial intervention (e.g., psychological therapy and integrated/collaborative care); probability of cost-effectiveness at explicitly defined thresholds reported. Comparators could be routine practice, no intervention, or alternative psychological therapies. Screening, data extraction, and critical appraisal were performed using pre-specified criteria and forms. Results were summarized qualitatively. The protocol was registered on the PROSPERO database (CRD42017056579).

RESULTS

Of 3,864 studies identified, 12 met the criteria for data extraction. All were integrated clinical and economic randomized controlled trials. The most common intervention was cognitive behavioral therapy (CBT, 6/12 studies). The most common measure of health benefit was the quality-adjusted life-year (6/12). Follow-up ranged from 6 months to 5 years. Interventions were found to be cost-effective in most studies (9/12): the probability of cost-effectiveness ranged from 35-99.5 percent. All studies had limitations and demonstrated uncertainty (particularly related to incremental costs).

CONCLUSIONS

Most studies concluded psychological interventions for schizophrenia/BD are cost-effective, including CBT, although there was notable uncertainty. Heterogeneity across studies makes it difficult to reach strong conclusions. There is a particular need for more evidence in the population with BD and for longer-term evidence across both populations.

Brain-based ranking of cognitive domains to predict schizophrenia

Schizophrenia is a devastating brain disorder that disturbs sensory perception, motor action, and abstract thought. Its clinical phenotype implies dysfunction of various mental domains, which has motivated a series of theories regarding the underlying pathophysiology. Aiming at a predictive benchmark of a catalog of cognitive functions, we developed a data-driven machine-learning strategy and provide a proof of principle in a multisite clinical dataset (n = 324). Existing neuroscientific knowledge on diverse cognitive domains was first condensed into neurotopographical maps. We then examined how the ensuing meta-analytic cognitive priors can distinguish patients and controls using brain morphology and intrinsic functional connectivity. Some affected cognitive domains supported well-studied directions of research on auditory evaluation and social cognition. However, rarely suspected cognitive domains also emerged as disease relevant, including self-oriented processing of bodily sensations in gustation and pain. Such algorithmic charting of the cognitive landscape can be used to make targeted recommendations for future mental health research.

Short-term versus long-term psychotherapy for adult psychiatric disorders: a protocol for a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

Psychiatric disorders are highly prevalent and associated with great symptomatic, functional, and health economic burdens. Psychotherapy is among the recommended and used interventions for most psychiatric disorders and is becoming widely accessible in mental health systems. The effects of specific forms of psychotherapy (e.g., psychodynamic therapies, cognitive and behavioral therapies, humanistic therapies, and systemic therapies) have been assessed previously in systematic reviews, but the appropriate psychotherapy duration for psychiatric disorders has not been reviewed. The aim of this systematic review will be to synthesize the evidence of the effects of short-term compared with long-term psychotherapy for all adult psychiatric disorders.

METHODS/DESIGN

A comprehensive search for relevant published literature will be undertaken in Cochrane Central Register of Controlled Trials (CENTRAL), Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica database (EMBASE), Latin American and Caribbean Health Sciences Literature (LILACS), PsycINFO, Science Citation Index Expanded (SCI-EXPANDED), Social Sciences Citation Index (SSCI), Conference Proceedings Citation Index-Science (CPCI-S), and Conference Proceedings Citation Index-Social Science & Humanities (CPCI-SSH) to identify relevant trials. We will search all databases from their inception to the present. We will include randomized clinical trials comparing a short-term and a long-term version of the same psychotherapy type for adult psychiatric disorders including attention deficit hyperactivity disorder, psychotic disorders, depressive disorders, bipolar disorders, anxiety disorders, obsessive-compulsive disorder, trauma- and stressor-related disorders, eating disorders, and personality disorders (as defined by standardized diagnostic criteria). We will rely on the trialists defining their compared interventions as short term and long term (or similar terminology). Primary outcomes will be quality of life, serious adverse events, and symptom severity. Secondary outcomes will be suicide or suicide attempts, self-harm, and level of functioning. Two review authors will independently extract data and perform risk of bias assessment using the Cochrane risk of bias tool. A meta-analysis will be performed as recommended by the Cochrane Handbook for Systematic Review of Interventions, bias will be assessed with domains, and Trial Sequential Analysis will be conducted to control random errors. Certainty of the evidence will be assessed by GRADE.

DISCUSSION

As psychotherapy is among the treatments of choice for most adult psychiatric disorders, a systematic review evaluating the benefits and harms of short-term compared with long-term psychotherapy is urgently needed. It is the hope that this review will be able to inform best practice in treatment and clinical research of these highly prevalent and burdensome disorders.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019128535.

Glutamate levels in the anterior cingulate cortex in un-medicated first episode psychosis: a proton magnetic resonance spectroscopy study

Converging lines of evidence suggest that glutamatergic dysfunction may contribute to the pathophysiology of first episode psychosis. We investigated whether first episode psychosis patients free from all pharmacological treatments and illicit substances show cortical glutamatergic alterations. One-hundred and eleven volunteers including 65 healthy volunteers and 46 first episode psychosis patients free from all pharmacological treatments (28 drug naïve) underwent a proton magnetic resonance spectroscopy scan measuring glutamate levels in the bilateral anterior cingulate cortex. Symptom severity was measured using the Positive and Negative Syndrome Scale (PANSS) and cognition was measured using the Wechsler Adult Intelligence Scale (WAIS) digit symbol test. There were no differences in glutamate levels between patients and controls. These findings remained unchanged when adjusting for the effects of age, sex and ethnicity or when restricting the analyses to patients who were both medication naïve to all pharmacological treatments and illicit substances. Whilst these findings do not preclude glutamatergic alterations in psychosis, methodological advances are needed for us to investigate whether patients show alterations in other aspects of glutamate function, such as pre-synaptic glutamate or release.

Prodromes and Preclinical Detection of Brain Diseases: Surveying the Ethical Landscape of Predicting Brain Health

The future of medicine lies not primarily in cures but in disease modification and prevention. While the science of preclinical detection is young, it is moving rapidly. Preclinical interventions offer hope to decrease the severity of a disease or delay the development of a disorder. With such promise, the research and practice of detecting brain disorders at a preclinical stage present unique ethical challenges that must be addressed to ensure the benefit of these technologies. Direct brain interventions have the potential to impact not just what a patient has but who they are and who they could become. Further, receiving an assessment for a preclinical or prodromal state has potential to impact perceptions about capacity, autonomy and personhood and could become entangled with stigma and discrimination. Exploring ethical issues alongside and integrated into the experimental design and research of these technologies is critical. This review will highlight ethical issues attendant to the current and near future states of preclinical detection across the life span, specifically as it relates to autism spectrum disorder (ASD), schizophrenia, and Alzheimer’s disease.

Assessing social recovery of vulnerable youth in global mental health settings: a pilot study of clinical research tools in Malaysia

BACKGROUND

A social recovery approach to youth mental health focuses on increasing the time spent in valuable and meaningful structured activities, with a view to preventing enduring mental health problems and social disability. In Malaysia, access to mental health care is particularly limited and little research has focused on identifying young people at risk of serious socially disabling mental health problems such as psychosis. We provide preliminary evidence for the feasibility and acceptability of core social recovery assessment tools in a Malaysian context, comparing the experiential process of engaging young Malaysian participants in social recovery assessments with prior accounts from a UK sample.

METHODS

Nine vulnerable young people from low-income backgrounds were recruited from a non-government social enterprise and partner organisations in Peninsular Malaysia. Participants completed a battery of social recovery assessment tools (including time use, unusual experiences, self-schematic beliefs and values). Time for completion and completion rates were used as indices of feasibility. Acceptability was examined using qualitative interviews in which participants were asked to reflect on the experience of completing the assessment tools. Following a deductive approach, the themes were examined for fit with previous UK qualitative accounts of social recovery assessments.

RESULTS

Feasibility was indicated by relatively efficient completion time and high completion rates. Qualitative interviews highlighted the perceived benefits of social recovery assessments, such as providing psychoeducation, aiding in self-reflection and stimulating goal setting, in line with findings from UK youth samples.

CONCLUSIONS

We provide preliminary evidence for the feasibility and acceptability of social recovery assessment tools in a low-resource context, comparing the experiential process of engaging young Malaysian participants in social recovery assessments with prior accounts from a UK sample. We also suggest that respondents may derive some personal and psychoeducational benefits from participating in assessments (e.g. of their time use and mental health) within a social recovery framework.

Electroconvulsive practice in Singapore: a cross-sectional national survey

INTRODUCTION

The use of electroconvulsive therapy (ECT) in Singapore dates back to 1947. However, there is little local information on the clinical practice of ECT and its standards. We aimed to conduct a comprehensive national survey of ECT practice in Singapore.

METHODS

A cross-sectional structured questionnaire assessing the types of ECT (e.g. electrode placement, stimulus parameters), indications, anaesthetic technique, dosing methods, monitoring of outcomes and credentialing was sent in 2015 to all ECT centres in Singapore via email to collect qualitative and quantitative data regarding ECT.

RESULTS

Data was obtained from all ECT centres (n = 6), which represented that ECT was available in 23.1% of all hospitals and 50.0% of all psychiatric specialist centres. The rate of ECT was 5.89 treatments per 10,000 residents per year, and each patient received an average of 5.4 ECT per course. Only 7.0% of ECT was administered for continuation/maintenance ECT. The most common indication for ECT was depression in 5 (83.3%) out of six centres, with schizophrenia being the second most common. In 5 (83.3%) out of six centres, ECT was brief (0.5 ms) bitemporal ECT with age-based dosing, and 93.0% of the sessions were conducted in an inpatient setting. All ECT was conducted under general anaesthesia, with propofol (66.7%) being the most common type of anaesthetic used.

CONCLUSION

The practice of ECT in Singapore was highly uniform. The rates and indications for ECT were consistent with those of other developed countries, with greater use of ECT for schizophrenia. Future advances for ECT in Singapore include the use of individualised dosing based on empirical seizure threshold titration, expanded electrode placements and increased utilisation of continuation/maintenance ECT.

Integrating genome-wide association study with regulatory SNP annotation information identified candidate genes and pathways for schizophrenia

BACKGROUND

Schizophrenia is a complex mental disorder. The genetic mechanism of schizophrenia remains elusive now.

METHODS

We conducted a large-scale integrative analysis of two genome-wide association studies of schizophrenia with functional annotation datasets of regulatory single-nucleotide polymorphism (rSNP). The significant SNPs identified by the two genome-wide association studies were first annotated to obtain schizophrenia associated rSNPs and their target genes and proteins, respectively. We then compared the integrative analysis results to identify the common rSNPs and their target regulatory genes and proteins, shared by the two genome-wide association studies of schizophrenia. Finally, DAVID tool was used to conduct gene ontology and pathway enrichment analysis of the identified targets genes and proteins.

RESULTS

We detected 53 schizophrenia-associated target genes for rSNP, such as FOS (P value = 2.18×10^-20), ATXN1 (P value = 5.22×10^-21) and HLA-DQA1 (P value = 1.98×10^-10). Pathway enrichment analysis identified 24 pathways for transcription factors binding regions, chromatin interacting regions, long non-coding RNAs, topologically associated domains, circular RNAs and post-translational modifications, such as hsa05034:Alcoholism (P value = 2.57×10^-7) and hsa04612:Antigen processing and presentation (P value = 6.82×10^-8).

CONCLUSION

We detected multiple candidate genes, gene ontology terms and pathways for schizophrenia, supporting the functional importance of rSNPs, and providing novel clues for understanding the genetic architecture of schizophrenia.

Adherence, Healthcare Resource Utilization, and Costs in Medicaid Beneficiaries with Schizophrenia Transitioning from Once-Monthly to Once-Every-3-Months Paliperidone Palmitate

OBJECTIVES

The aim was to compare adherence to antipsychotics (APs), healthcare resource utilization (HRU), and costs before and after once-every-3-months paliperidone palmitate (PP3M) initiation in patients with schizophrenia.

METHODS

Medicaid data (Iowa, Kansas, and Missouri; 1/2014-3/2017) were used to identify adults with at least one PP3M claim, ≥ 12 months of pre-index enrollment, and at least two schizophrenia diagnoses. Adequate treatment with once-monthly paliperidone palmitate (PP1M) was required pre-PP3M transition. Generalized estimating equations were used to assess linear trends in adherence to APs, HRU, and costs over the four quarters pre-PP3M transition, and to compare monthly HRU and costs 6 months pre- and 12 months post-PP3M transition as well as adherence to APs 12 months pre- and post-PP3M transition.

RESULTS

Among 324 patients initiated on PP3M, the mean age was 41.4 years and 36.1% were females. Over the four quarters pre-PP3M transition, the monthly number of emergency room visits, medical costs, and inpatient costs decreased, while pharmacy costs and adherence to APs increased. For patients with ≥ 12 months of follow-up (n = 151), adherence to APs (66.2 vs. 70.2%, p = 0.3758), total (US$3371 vs. US$3456; p = 0.7000), pharmacy (US$1805 vs. US$1870; p = 0.2960), and medical costs (US$1565 vs. US$1586; p = 0.9040) remained similar pre- and post-PP3M transition, while mean monthly number of 1-day mental institute visits (1.71 vs. 1.51; p < 0.01) and associated costs (US$260 vs. US$232, p = 0.01) decreased.

CONCLUSIONS

Adherence to APs, HRU, and costs were similar pre- and post-PP3M transition, suggesting that PP3M has no impact on monthly costs for patients adequately treated with PP1M, with the added flexibility of once-every-3-months dosing.

The therapeutic needs of psychiatric in-patients with psychosis: A qualitative exploration of patient and staff perspectives

BACKGROUND

Concerns are recurrently expressed that the therapeutic content of in-patient care is limited and lacking clear guidance. The perspectives of patients and staff regarding therapeutic priorities for psychiatric in-patient care have been little explored and compared.

AIMS

The aim of this study was to examine patient and staff perspectives on the care priorities of psychiatric in-patients with psychosis.

METHOD

We recruited 12 in-patients with psychosis and 12 multidisciplinary team staff. All participants undertook a semi-structured interview examining their perspectives on the therapeutic needs of people with psychosis during admission. Interviews were transcribed verbatim and thematic analysis conducted.

RESULTS

Three superordinate themes arose from patient interviews: 'the importance of considering social circumstances and trauma', 'managing the intra- and interpersonal impact of psychosis' and 'lack of control and collaboration in care' and three from staff interviews: 'multidisciplinary facilitators of care', 'treating complexity and incorporating social factors' and 'restrictive practices preventing quality care provision'. Comparison of patient and staff themes identified unmet needs in addressing social marginalisation, trauma and distress, and the importance of collaborative treatment process and inclusion of spirituality.

CONCLUSIONS

There are gaps between staff and patient perspectives on important priorities for in-patient care that may help explain persistent patient dissatisfaction with in-patient care. Findings suggest the need for coproduced work to develop and test interventions that address broader therapeutic priorities.

DECLARATION OF INTEREST

None.

A systematic review of the indirect costs of schizophrenia in Europe

Background

Schizophrenia is a chronic disease associated with significant and long-lasting effects on health, and it is also a social and financial burden, not only for patients but also for families, other caregivers, and the wider society. It is essential to conduct the assessment of indirect costs, to understand all the effects of the disease on society. Our aim is to gain a better understanding of the indirect costs of schizophrenia in Europe.

Methods

We conducted a comprehensive systematic literature review covering EMBASE, Medline, and PsycINFO as well as reviewing Health Technology Assessment databases from different countries. We used a qualitative research synthesis for presenting information, as most of the studies were methodologically diverse, a quantitative analysis would have been impractical.

Results

Indirect cost adjusted to inflation ranged vastly between studies included in the review from 119 Euros to 62, 034 Euros annually. The average proportion of indirect costs of total costs was 44%. Studies highlighted important cost drivers as age, gender, and disease severity, explaining the variation in costs between treatment and patient groups.

Conclusions

Regardless of the methodological heterogeneity of the reviewed studies, there was an agreement about the significance of indirect costs of schizophrenia on the society. Considering the relatively high prevalence of schizophrenia in Europe, a need for more cost of illness studies especially from Central Eastern and Southern Europe is suggested.

Saccadic eye movements in different dimensions of schizophrenia and in clinical high-risk state for psychosis

BACKGROUND

Oculomotor dysfunction is one of the most replicated findings in schizophrenia. However the association between saccadic abnormalities and particular clinical syndromes remains unclear. The assessment of saccadic movements in schizophrenia patients as well as in clinical high-risk state for psychosis individuals (CHR) as a part of schizophrenia continuum may be useful in validation of saccadic movements as a possible biomarker.

METHODS

The study included 156 patients who met the ICD-10 criteria for schizophrenia: 42 individuals at clinical high-risk-state for psychosis and 61 healthy controls. The schizophrenia patients had three subgroups based on the sum of the global SAPS and SANS scores: (1) patients with predominantly negative symptoms (NS, n = 62); (2) patients with predominantly positive symptoms (PS, n = 54) (3) patients with predominantly disorganization symptoms (DS, n = 40). CHR subjects were characterized by the presence of one of the groups of criteria: (1) Ultra High Risk criteria, (2) Basic Symptoms criteria or (3) negative symptoms and formal thought disorders. Horizontal eye movements were recorded by using videonystagmograph. We measured peak velocity, latency and accuracy in prosaccade, antisaccade and predictive saccade tasks as well as error rates in the antisaccade task.

RESULTS

Schizophrenia patients performed worse than controls in predictive, reflexive and antisaccade tasks. Oculomotor parameters of NS were different from the other groups of patients. Latencies of predictive and reflexive saccades were significantly longer than in controls only in the NS group. The accuracy of predictive saccades was also different from controls only in the NS schizophrenia group. More prominent loss of accuracy of reflexive saccades was found in the DS group and it significantly differed from the one in other groups. Participants from DS group made more errors in antisaccade task compared to NS and PS groups. CHR subjects performed worse than controls as measured by the accuracy of reflexive saccades and antisaccades.

CONCLUSIONS

The study confirms the existence of different relations between the symptom dimensions of schizophrenia and saccades tasks performances. Saccadic abnormalities were revealed in the clinical (schizophrenia) and pre-clinical (clinical high risk) populations that provide further evidence for assessing saccadic abnormalities as a possible neurobiological marker for schizophrenia.

Brexpiprazole: A Review in Schizophrenia

Brexpiprazole (Rxulti^®, Rexulti^®) is an oral atypical antipsychotic agent approved for the treatment of schizophrenia in the EU (in adult patients) and the USA, as well as in some other countries, including Japan. Like aripiprazole, it is a partial agonist at dopamine D₂ and serotonin 5-HT_1A receptors and an antagonist at serotonin 5-HT_2A receptors. However, brexpiprazole displays less intrinsic activity at D₂ receptors and, coupled with actions at 5HT_1A, 5HT_2A and noradrenaline α_1B receptors that are at least as potent as its action at D₂ receptors, is predicted to demonstrate a lower propensity for activating adverse events and extrapyramidal symptoms than aripiprazole. Brexpiprazole 2-4 mg/day produced statistically significant and clinically meaningful improvements in overall symptomatology and psychosocial functioning compared with placebo in adults with acute exacerbation of schizophrenia. As maintenance treatment, brexpiprazole 1-4 mg/day significantly delayed the time to relapse compared with placebo in patients who were already stabilized on the drug and was associated with stabilization or continued improvement in patients' symptoms and functioning. Brexpiprazole was generally well tolerated, exhibiting an adverse event profile characterized by a relatively low incidence of activating and sedating adverse effects, small changes in QT interval and metabolic parameters that were not clinically significant, and moderate weight gain. Clinical evidence to date suggests it usefully extends the range of therapeutic options for schizophrenia.

Specialised early intervention teams (extended time) for first episode psychosis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

The primary objective is to compare extended early intervention (EEIP) specialised team care to usual community mental health care for the treatment of people with first episode psychosis (FEP). The secondary objective is to compare the effectiveness of EEIP specialised team care to standard early intervention (SEIP) specialised team care (i.e. to test whether there is a dose‐response effect).

Genetic Association of Olanzapine Treatment Response in Han Chinese Schizophrenia Patients

Olanzapine, a second-generation antipsychotic medication, plays a critical role in current treatment of schizophrenia (SCZ). It has been observed that the olanzapine responses in schizophrenia treatment are different across individuals. However, prediction of this individual-specific olanzapine response requires in-depth knowledge of biomarkers of drug response. Here, we performed an integrative investigation on 238 Han Chinese SCZ patients to identify predictive biomarkers that were associated with the efficacy of olanzapine treatment. This study applied HaloPlex technology to sequence 143 genes from 79 Han Chinese SCZ patients. Our result suggested that there were 12 single nucleotide polymorphisms (SNPs) had significant association with olanzapine response in Han Chinese SCZ patients. Using MassARRAY platform, we tested that if these 12 SNPs were also statistically significant in 159 other SCZ patients (independent cohort) and the combined 238 SCZ patients (composed of two tested cohorts). The result of this analysis showed that 2 SNPs were significantly associated with the olanzapine response in both independent cohorts (rs324026, P = 0.023; rs12610827, P = 0.043) and combined SCZ patient population (rs324026, adjust P = 0.014; rs12610827, adjust P = 0.012). Our study provides systematic analyses of genetic variants associated with olanzapine responses of Han Chinese SCZ patients. The discovery of these novel biomarkers of olanzapine-response will facilitate to advance future olanzapine treatment specific for Han Chinese SCZ patients.

Economic Cost of Schizophrenia in a Nigerian Teaching Hospital

Objective:

This study evaluated the economic cost of schizophrenia in Nigerian patients and identified factors that influence cost.

Methods:

A total of 100 participants with schizophrenia were assessed using the modified economic cost questionnaire, the mini-international neuropsychiatric interview, the positive and negative syndrome scale, the Liverpool University Neuroleptic side-effect rating scale, and the global assessment of functioning scale. Associations between sociodemographic characteristics, illness-related variables and direct, indirect, and total costs of schizophrenia were assessed.

Results:

The average annual total, direct, and indirect costs of the treatment were $818.48, $349.59, and $468.89, respectively, per patient. The direct cost constituted 42.7%, while the indirect cost was 57.3% of the total costs of treatment. Hospitalization was the leading contributor to the direct cost, while productivity loss was a major component of the indirect cost.

Conclusion:

Schizophrenia is an expensive disease in Nigeria, measures to reduce hospitalization could significantly reduce the cost of illness to the patient and their relatives.

Literature review and economic evaluation of oral and intramuscular ziprasidone treatment among patients with schizophrenia in China

Background

Over 10 million Chinese are affected by schizophrenia. The annual cost of schizophrenia in China was estimated at US$2586 per patient.

Aims

The study has two aims: (1) to conduct a targeted literature review of the economic literature on oral ziprasidone in China, and (2) to develop an inpatient economic model that compared the cost of intramuscular ziprasidone with other regimens including electroconvulsive therapy (ECT) for the management of acute agitation in patients with schizophrenia from a hospital’s perspective in China.

Methods

A targeted literature review was conducted using PubMed and the Chinese literature databases for studies published between January 2007 and December 2017. Studies that assessed costs associated with oral ziprasidone treatment for schizophrenia in China were summarised. In the inpatient economic model, cost measures included hospital room and board, antipsychotics, ECT and medications for the management of extrapyramidal symptoms (EPS). Input for standard antipsychotic regimens and unit cost were obtained from the literature. Hospital length of stay (LOS), utilisation of ECT and incidence of EPS were derived from the literature and supplemented/validated with a survey of psychiatrists in China. Cost was presented in 2017 Chinese yuan.

Results

The average estimated LOS was 29 days with ziprasidone, 33 days with risperidone+benzodiazepine, 32 days with olanzapine, 35 days with haloperidol and 29 days with ECT. The cost of antipsychotics was ¥1260 with ziprasidone, ¥137 with risperidone+benzodiazepine, ¥913 with olanzapine and ¥210 with haloperidol; ECT treatment cost ¥785. The base-case analysis suggested that higher antipsychotic cost with ziprasidone was offset by savings with shorter LOS. Using intramuscular ziprasidone for acute management was associated with a total cost of ¥11 157, the lowest among all antipsychotic regimens (¥11 424 with risperidone+benzodiazepine, ¥11 711 with olanzapine and ¥11 912 with haloperidol) and slightly higher than ECT (¥10 606). The cost of antipsychotics and ECT accounted for 1 %–11 % of the total cost. Varying LOS between the lower and upper bounds of the 95% CI, the total cost was comparable between these regimens.

Conclusions

Overall, the cost for the management of acute agitation was similar between intramuscular ziprasidone and other antipsychotics. Compared with other antipsychotics, the higher medication cost of intramuscular ziprasidone can be offset by savings with shorter hospital stay. The results from this economic analysis were complementary to the findings in the published literature assessing the economic outcomes of oral ziprasidone.

Role of paliperidone palmitate 3-monthly in the management of schizophrenia: insights from clinical practice

Schizophrenia is a complex, chronic psychiatric disorder associated with reduced quality of life and shortened life span. The majority of patients with schizophrenia will relapse within 1 year following an acute episode. The ultimate goals of treatment are to improve functional capabilities, minimize residual symptoms during periods of remission, and decrease relapse frequency and duration, as each relapse brings with it the possibility of a worsening prognosis. Maintaining therapeutic continuity is essential for long-term, positive patient outcomes in schizophrenia. Medication nonadherence and symptomatic relapses magnify the disease burden associated with this disorder. Medication adherence in chronic disease states generally improves with a decrease in dosing frequency. Long-acting injectable (LAI) antipsychotics were developed to improve patient outcomes secondarily to improving medication adherence. Paliperidone palmitate 3-monthly injection (PP3M) is the only LAI available with a quarterly dosing interval. PP3M has been US Food and Drug Administration-approved for use in the long-term maintenance treatment of schizophrenia in patients already controlled on once-monthly PP LAI (paliperidone palmitate once-monthly injection [PP1M]) for a minimum of 4 months. As current evidence supports the efficacy and tolerability of PP3M compared to PP1M and placebo, PP3M appears to be a viable treatment option for patients previously maintained on PP1M. However, to truly establish the place of PP3M in therapy relative to other oral antipsychotics and LAIs, more research is needed. This narrative review aims briefly to describe the pharmacotherapeutic characteristics of PP3M and summarize current literature pertaining to the use of PP3M in the management of schizophrenia.

Paliperidone, a relatively novel atypical antipsychotic drug, is a substrate for breast cancer resistance protein

Paliperidone (PAL) is a relatively novel atypical antipsychotic drug for schizophrenia that induces markedly varying responses. Breast cancer resistance protein (BCRP) is a recently discovered member of the ATP-binding cassette superfamily that has been used to control drug absorption, distribution and elimination, and especially to impede drug entry into the brain. To the best of our knowledge, the present study is the first to investigate the possibility of using PAL as a BCRP substrate. The intracellular accumulation and bidirectional transport were investigated using transfected 293 cell/BCRP and porcine renal endothelial cell (LLC-PK1)/BCRP cell monolayers and BCRP overexpression was confirmed by reverse transcription-quantitative polymerase chain reaction and western blot analysis. The in vitro affinity to BCRP was assessed in human BCRP (Arg482) membranes. The intracellular accumulation and bidirectional transport investigations demonstrated that BCRP can efflux PAL from cells and significantly decrease its cellular concentration over a concentration range of 0.1-50 µM. The in vitro affinity experiments indicated that PAL has a moderate affinity to BCRP at 0.1-100 µM. These results together suggest that PAL is a substrate for BCRP and that it can affect the blood-brain barrier penetration of PAL at therapeutic dosages.

microRNAs Sculpt Neuronal Communication in a Tight Balance That Is Lost in Neurological Disease

Since the discovery of the first microRNA 25 years ago, microRNAs (miRNAs) have emerged as critical regulators of gene expression within the mammalian brain. miRNAs are small non-coding RNAs that direct the RNA induced silencing complex to complementary sites on mRNA targets, leading to translational repression and/or mRNA degradation. Within the brain, intra- and extracellular signaling events tune the levels and activities of miRNAs to suit the needs of individual neurons under changing cellular contexts. Conversely, miRNAs shape neuronal communication by regulating the synthesis of proteins that mediate synaptic transmission and other forms of neuronal signaling. Several miRNAs have been shown to be critical for brain function regulating, for example, enduring forms of synaptic plasticity and dendritic morphology. Deficits in miRNA biogenesis have been linked to neurological deficits in humans, and widespread changes in miRNA levels occur in epilepsy, traumatic brain injury, and in response to less dramatic brain insults in rodent models. Manipulation of certain miRNAs can also alter the representation and progression of some of these disorders in rodent models. Recently, microdeletions encompassing MIR137HG, the host gene which encodes the miRNA miR-137, have been linked to autism and intellectual disability, and genome wide association studies have linked this locus to schizophrenia. Recent studies have demonstrated that miR-137 regulates several forms of synaptic plasticity as well as signaling cascades thought to be aberrant in schizophrenia. Together, these studies suggest a mechanism by which miRNA dysregulation might contribute to psychiatric disease and highlight the power of miRNAs to influence the human brain by sculpting communication between neurons.

Direct medical costs for patients with schizophrenia: a 4-year cohort study from health insurance claims data in Guangzhou city, Southern China

BACKGROUND

Schizophrenia is one of the leading public health issues in psychiatry and imposes a heavy financial burden on the healthcare systems. This study aims to report the direct medical costs and the associated factors for patients with schizophrenia in Guangzhou city, Southern China.

METHODS

This was a retrospective 4-year cohort study. Data were obtained from urban health insurance claims databases of Guangzhou city, which contains patients' sociodemographic characteristics, direct medical costs of inpatient and outpatient care. The study cohort (including all the reimbursement claims submitted for schizophrenia inpatient care during November 2010 and October 2014) was identified using the International Classification of Diseases Tenth version (F20). Their outpatient care information was merged from outpatient claims database. Descriptive analysis and the multivariate regression analysis based on Generalized Estimating Equations model were conducted.

RESULTS

A total of 2971 patients were identified in the baseline. The cohort had a mean age of 50.3 years old, 60.6% were male, and 67.0% received medical treatment in the tertiary hospitals. The average annual length of stay was 254.7 days. The average annual total direct medical costs per patient was 41,972.4 Chinese Yuan (CNY) ($6852.5). The inpatient costs remained as the key component of total medical costs. The Urban Employee Basic Medical Insurance enrollees with schizophrenia had higher average costs for hospitalization (CNY42,375.1) than the Urban Resident Basic Medical Insurance enrollees (CNY40,917.3), and had higher reimbursement rate (85.8% and 61.5%). The non-medication treatment costs accounted for the biggest proportion of inpatient costs for both schemes (55.8% and 64.7%). Regression analysis suggested that insurance type, age, hospital levels, and length of stay were significantly associated with inpatient costs of schizophrenia.

CONCLUSIONS

The direct annual medical costs of schizophrenia were high and varied by types of insurance in urban China. The findings of this study provide vital information to understand the burden of schizophrenia in China. Results of this study can help decision-makers assess the financial impact of schizophrenia.

Economic evaluation of brief cognitive behavioural therapy for social activation in recent-onset psychosis

Background

In schizophrenia spectrum disorders, negative symptoms (e.g. social withdrawal) may persist after initial treatment with antipsychotics, much affecting the quality of life (QOL) of patients. This health-economic study evaluated if a dedicated form of cognitive behaviour therapy for social activation (CBTsa) would reduce negative symptoms and improve QOL in an economically sustainable way.

Methods

A health-economic evaluation was conducted alongside a single-blind randomised controlled trial in two parallel groups: guideline congruent treatment as usual (TAU; n = 50) versus TAU augmented with adjunct CBTsa (n = 49). Outcomes were PANSS negative symptom severity and EQ-5D quality adjusted life years (QALYs) gained. The health-economic evaluation was conducted both from the societal and the health sector perspective.

Results

Both conditions showed improvement in the respective outcomes over the follow-up period of six months, but QALY gains were significantly higher in the CBTsa condition compared to the TAU condition. Treatment response rate (i.e. ≥ 5-point decrease on the PANSS) was not significantly different. However, the add-on CBT intervention was associated with higher costs. This did not support the idea that CBTsa is a cost-effective adjunct. Various sensitivity analyses attested to the robustness of these findings.

Conclusions

In the Dutch context where TAU for psychosis is guideline congruent and well implemented there appears no added value for adjunct CBTsa. In other settings where the treatment for the schizophrenia spectrum disorders solely relies on antipsychotics, add-on CBTsa may lead to clinically superior outcomes, but it should still be evaluated if adjunct CBTsa therapy is a cost-effective alternative.

Trial registration

ClinicalTrials.gov registry under NCT03217955.

Mapping the Positive and Negative Syndrome Scale scores to EQ-5D-5L and SF-6D utility scores in patients with schizophrenia

OBJECTIVE

The current study aims to map the Positive and Negative Syndrome Scale (PANSS) onto the five-level EuroQol five-dimensional (EQ-5D-5L) and Short Form six-dimensional (SF-6D) utility scores for patients with schizophrenia.

METHODS

A total of 239 participants with schizophrenia spectrum disorder were recruited from a tertiary psychiatric hospital in Singapore. Ordinary least squares (OLS), censored least absolute deviations and Tobit regression methods were employed to estimate utility scores from the EQ-5D-5L and SF-6D. Model selection of the 18 regression models (three regression methods × six model specifications) was primarily determined by the smallest mean absolute error and mean square error, and the largest R² and adjusted R².

RESULTS

The mean age of the sample was 39.7 years (SD = 10.3). The mean EQ-5D-5L and SF-6D utility scores were 0.81 and 0.68, respectively. The EQ-5D-5L utility scores were best predicted by the OLS regression model consisting of three PANSS subscales, i.e. positive, negative and general psychopathology symptoms, and covariates including age and gender. The SF-6D was best predicted by OLS regression model consisting of five PANSS subscales, i.e. positive, negative, excitement, depression and cognitive subscales.

CONCLUSION

The current study provides important evidence to clinicians and researchers on mapping algorithms for converting PANSS scores into utility scores that can be easily applicable for cost-utility analysis when EQ-5D-5L and SF-6D data are not available for patients with schizophrenia spectrum disorder in Singapore.

Comparative efficacy and safety between amisulpride and olanzapine in schizophrenia treatment and a cost analysis in China: a systematic review, meta-analysis, and cost-minimization analysis

BACKGROUND

Amisulpride was introduced into China in 2010 as a second-generation atypical antipsychotic, while olanzapine has been on the market since 1999 as one of the leading treatments for schizophrenia in China. Since more Chinese patients are gaining access to amisulpride, the study aims to compare the efficacy, safety, and costs between amisulpride and olanzapine for schizophrenia treatment in China.

METHODS

PubMed, Embase, the Cochrane library, China National Knowledge Infrastructure (CNKI) and WanFang database were systematically searched for randomized controlled trials (RCTs) up to July 2018. The Cochrane Risk of Bias tool was utilized to assess the quality of included studies. A meta-analysis was performed to compare the efficacy and safety of amisulpride and olanzapine, followed by a cost-minimization analysis using local drug and medical costs reported in China.

RESULTS

Twenty RCTs with 2000 patients were included in the systematic review. There were no significant differences between amisulpride and olanzapine on efficacy measures based on scores from the Positive and Negative Syndrome Scale, the Scale for the Assessment of Negative Symptoms, the Brief Psychiatric Rating Scale and the Clinical Global Impressions-Severity or Improvement. For safety outcomes, amisulpride was associated with lower fasting blood glucose and less abnormal liver functions as well as significantly lower risks of weight gain, constipation, and somnolence; olanzapine was associated with significantly lower risks of insomnia and lactation/amenorrhea/sexual hormone disorder. No significant differences were found in risks of extrapyramidal symptoms (EPS), tremor, akathisia, abnormal corrected QT interval. Cost-minimization analysis showed that amisulpride was likely to be a cost-saving alternative in China, with potential savings of 1358 Chinese Yuan (CNY) per patient for a three-month schizophrenia treatment compared with olanzapine.

CONCLUSION

As the first meta-analysis and cost-minimization analysis comparing the efficacy, safety and cost of amisulpride and olanzapine within a Chinese setting, the study suggests that amisulpride may be an effective, well-tolerated, and cost-saving antipsychotic drug alternative in China.

An open-treatment six-week study of the clinical effectiveness of Paliperidone Palmitate in schizophrenia: data from acute units in Spain (SHADOW study)

OBJECTIVES

To evaluate clinical evolution of patients with schizophrenia admitted in acute units because of a relapse and treated with once-monthly Paliperidone Palmitate (PP1M).

METHODS

This multicentre, open-label, prospective observational study followed patients with schizophrenia treated with PP1M in acute psychiatric units for up to 6 weeks.

RESULTS

Out of the 280 enrolled patients, 61 received PP1M as antipsychotic monotherapy, and 219 in combination with other antipsychotics. The average Clinical Global Impression-Schizophrenia (CGI-SCH) score decreased from 4.7 at baseline to 3.3 at final visit (p < .0001); the change was clinically and statistically significant both in patients treated with PP1M in monotherapy and in combination with other antipsychotics. Clear improvements in functioning and high patient satisfaction with the treatment were observed. Time from admission to PP1M therapy initiation correlated with the length of hospital stay (p < .0001); earlier start of PP1M treatment was associated with shorter hospital stay. Adverse events were reported in 7.1% of patients (all non-serious).

CONCLUSIONS

PP1M was effective and well tolerated in treatment of acute episodes of schizophrenia both in monotherapy and in combination with other antipsychotics in clinical setting. Early start of PP1M therapy in acute schizophrenia episodes might help to shorten hospital stay.

Exploring the potential of civic engagement to strengthen mental health systems in Indonesia (IGNITE): a study protocol

Background

Indonesia has the highest rate of years of life lost to disability or early death from Schizophrenia than any other country in the world. More than 90% of people with mental illness do not get any treatment and tens of thousands of people with psychosis are illegally detained (‘pasung’) in the family home. Civic engagement, a core part of the recent World Health Organisation global strategy, has the potential to address some of these challenges through the development of person-centered models of care. The aim of the study is to develop a testable systems level, culturally appropriate, civic engagement framework for use in Jakarta and Bogor, Indonesia to strengthen local mental health services.

Methods

A mixed methods study underpinned by a realist approach will be undertaken across four phases in two study sites in Indonesia (Jakarta and Bogor). Phase 1 will explore the use of civic engagement across South East Asia by conducting a systematic review of existing evidence. By surveying 300 mental health professionals, phase 2 will identify the stakeholders, the sources of collaboration and the evidence used by professionals in decision making within local mental health systems and identify potential opportunities for civic engagement within the system. In order to explore the potential use of civic engagement within Indonesian mental health services and identify priorities for a culturally appropriate framework, phase 3 will undertake two focus groups with participants with experience of psychosis or caring for someone with psychosis (n = 20–30). Professionals and other key decision makers in a range of roles across the system at a national (n = 5) and local level (n = 10–15/site) will also take part in semi-structured interviews. Phase 4 will co-produce a civic engagement framework for use in Indonesia by synthesising evidence from phases 1–3 collaboratively with key stakeholders.

Discussion

Civic engagement is a potential way in which health services in low and middle income countries can address the burden of mental health conditions through the development of person-centred models of care. However, such approaches are underexplored in Indonesia. This study will work with local stakeholders to design a testable civic engagement framework for use in mental health services in Indonesia.

Electronic supplementary material

The online version of this article (10.1186/s13033-018-0227-x) contains supplementary material, which is available to authorized users.

Proteomics for blood biomarker exploration of severe mental illness: pitfalls of the past and potential for the future

Recent improvements in high-throughput proteomic approaches are likely to constitute an essential advance in biomarker discovery, holding promise for improved personalized care and drug development. These methodologies have been applied to study multivariate protein patterns and provide valuable data of peripheral tissues. To highlight findings of the last decade for three of the most common psychiatric disorders, namely schizophrenia (SZ), bipolar disorder (BD), and major depressive disorder (MDD), we queried PubMed. Here we delve into the findings from thirty studies, which used proteomics and multiplex immunoassay approaches for peripheral blood biomarker exploration. In an explorative approach, we ran enrichment analyses in peripheral blood according to these results and ascertained the overlap between proteomic findings and genetic loci identified in genome-wide association studies (GWAS). The studies we appraised demonstrate that proteomics for psychiatric research has been heterogeneous in aims and methods and limited by insufficient sample sizes, poorly defined case definitions, methodological inhomogeneity, and confounding results constraining the conclusions that can be extracted from them. Here, we discuss possibilities for overcoming methodological challenges for the implementation of proteomic signatures in psychiatric diagnosis and offer an outlook for future investigations. To fulfill the promise of proteomics in mental disease diagnostics, future research will need large, well-defined cohorts in combination with state-of-the-art technologies.

Expression Analysis of CYFIP1 and CAMKK2 Genes in the Blood of Epileptic and Schizophrenic Patients

Schizophrenia and epilepsy are two prevalent neurological disorders with high global burden to the society. Genome-wide studies have identified potential underlying causes for these neurological diseases. In the present case-control study, we have assessed expression of CYFIP1 and CAMKK2 genes in the blood samples of epileptic and schizophrenic patients compared with healthy subjects. A total of 180 subjects including 40 epileptic patients, 50 schizophrenic patients, and 90 healthy individuals participated in the study. Expression of the mentioned genes was measured using TaqMan real-time PCR. The results demonstrated a significant upregulation of CYFIP1 gene expression in epileptic patients (P = 0.029). CAMKK2 was downregulated in female schizophrenic patients compared with female healthy individuals (P = 0.048). These results may provide new insight into the pathogenesis of epilepsy and schizophrenia and suggest these genes as potential therapeutic targets for these neurological disorders. Future studies should evaluate these results in larger cohorts of patients.

Trajectories and changes in individual items of positive and negative syndrome scale among schizophrenia patients prior to impending relapse

Effective early detection of impending relapse may offer opportunities for early interventions to prevent full relapse in schizophrenia patients. Previously reported early warning signs were not consistently validated by prospective studies. It remains unclear which symptoms are most predictive of relapse. To prioritize the symptoms to be captured by periodic self-report in technology-enabled remote assessment solutions for monitoring symptoms and detecting relapse early, we analyzed data from three relapse-prevention studies to identify individual items of the Positive and Negative Syndrome Scale (PANSS) that changed the most prior to relapse and to understand exactly when these symptoms manifested. Relapse was defined by a composite endpoint: hospitalization, suicidal/homicidal ideation, violent behavior, a 25% increase in the PANSS total score, or a significant increase in at least one of several pre-specified PANSS items. Longitudinal mixed effect models were applied to model the trajectories of individual PANSS items before relapse. Among 267 relapsed patients, the PANSS items that increased the most at relapse from randomization did not differ much by different relapse reasons or medications. A subset of seven PANSS items, including delusions, suspiciousness, hallucinations, anxiety, excitement, tension, and conceptual disorganization, had on average > 1-point of increase at relapse. The trajectories of these items suggested these items started to increase 7-10 days before relapse and reached on average 1-point of increase 0.3 ~ 1.2 days before relapse. Our results indicated that a subset of PANSS items could be leveraged to develop remote assessment solutions for monitoring symptoms and detecting relapse early in schizophrenia patients.

Genetic risk scores and family history as predictors of schizophrenia in Nordic registers

BACKGROUND

Family history is a long-standing and readily obtainable risk factor for schizophrenia (SCZ). Low-cost genotyping technologies have enabled large genetic studies of SCZ, and the results suggest the utility of genetic risk scores (GRS, direct assessments of inherited common variant risk). Few studies have evaluated family history and GRS simultaneously to ask whether one can explain away the other.

METHODS

We studied 5959 SCZ cases and 8717 controls from four Nordic countries. All subjects had family history data from national registers and genome-wide genotypes that were processed through the quality control procedures used by the Psychiatric Genomics Consortium. Using external training data, GRS were estimated for SCZ, bipolar disorder (BIP), major depression, autism, educational attainment, and body mass index. Multivariable modeling was used to estimate effect sizes.

RESULTS

Using harmonized genomic and national register data from Denmark, Estonia, Norway, and Sweden, we confirmed that family history of SCZ and GRS for SCZ and BIP were risk factors for SCZ. In a joint model, the effects of GRS for SCZ and BIP were essentially unchanged, and the effect of family history was attenuated but remained significant. The predictive capacity of a model including GRS and family history neared the minimum for clinical utility.

CONCLUSIONS

Combining national register data with measured genetic risk factors represents an important investigative approach for psychotic disorders. Our findings suggest the potential clinical utility of combining GRS and family history for early prediction and diagnostic improvements.

Prevalence of psychotic disorders and its association with methodological issues. A systematic review and meta-analyses

Objectives

The purpose of this study is to provide an updated systematic review to identify studies describing the prevalence of psychosis in order to explore methodological factors that could account for the variation in prevalence estimates.

Methods

Studies with original data related to the prevalence of psychosis (published between 1990 and 2015) were identified via searching electronic databases and reviewing manual citations. Prevalence estimates were sorted according to prevalence type (point, 12-months and lifetime). The independent association between key methodological variables and the mean effect of prevalence was examined (prevalence type, case-finding setting, method of confirming diagnosis, international classification of diseases, diagnosis category, and study quality) by meta-analytical techniques and random-effects meta-regression.

Results

Seventy-three primary studies were included, providing a total of 101 estimates of prevalence rates of psychosis. Across these studies, the pooled median point and 12-month prevalence for persons was 3.89 and 4.03 per 1000 respectively; and the median lifetime prevalence was 7.49 per 1000. The result of the random-effects meta-regression analysis revealed a significant effect for the prevalence type, with higher rates of lifetime prevalence than 12-month prevalence (p<0.001). Studies conducted in the general population presented higher prevalence rates than those carried out in populations attended in health/social services (p = 0.006). Compared to the diagnosis of schizophrenia only, prevalence rates were higher in the probable psychotic disorder (p = 0.022) and non-affective psychosis (p = 0.009). Finally, a higher study quality is associated with a lower estimated prevalence of psychotic disorders (p<0.001).

Conclusions

This systematic review provides a comprehensive comparison of methodologies used in studies of the prevalence of psychosis, which can provide insightful information for future epidemiological studies in adopting the most relevant methodological approach.

Attenuated Notch signaling in schizophrenia and bipolar disorder

The Notch signaling pathway plays a crucial role in neurodevelopment and in adult brain homeostasis. We aimed to further investigate Notch pathway activity in bipolar disorder (BD) and schizophrenia (SCZ) by conducting a pathway analysis. We measured plasma levels of Notch ligands (DLL1 and DLK1) using enzyme immunoassays in a large sample of patients (SCZ n = 551, BD n = 246) and healthy controls (HC n = 639). We also determined Notch pathway related gene expression levels by microarray analyses from whole blood in a subsample (SCZ n = 338, BD n = 241 and HC n = 263). We found significantly elevated Notch ligand levels in plasma in both SCZ and BD compared to HC. Significant gene expression findings included increased levels of RFNG and KAT2B (p < 0.001), and decreased levels of PSEN1 and CREBBP in both patient groups (p < 0.001). RBPJ was significantly lower in SCZ vs HC (p < 0.001), and patients using lithium had higher levels of RBPJ (p < 0.001). We provide evidence of altered Notch signaling in both SCZ and BD compared to HC, and suggest that Notch signaling pathway may be disturbed in these disorders. Lithium may ameliorate aberrant Notch signaling. We propose that drugs targeting Notch pathway could be relevant in the treatment of psychotic disorders.

Palliative care for people with schizophrenia: a qualitative study of an under-serviced group in need

Background

People with schizophrenia are at risk of receiving poorer end of life care than other patients. They are often undertreated, avoid treatment and are about half as likely to access palliative care. There are limited options for end of life care for this under-serviced group in need. This study aims to address the paucity of research by documenting possible need, experiences of health care service use and factors affecting palliative care use for people with schizophrenia who have advanced life limiting illness.

Methods

Semi-structured interviews were undertaken with 16 experienced health professionals caring for people with schizophrenia in Western Australia. The interviews focussed on their perceptions and experiences of end of life care, their patients’ unmet needs, palliative care options, and suggested services to support this vulnerable group and improve health care provision. The research used a qualitative design and thematic analyses.

Results

The participants all advocated strongly for their patients and recognised their extreme vulnerability. They identified a range of challenges and unmet needs experienced by people with schizophrenia at the end of life including: illness factors such as the impact of schizophrenia on information processing and communication; social factors such as stigma, isolation and the absence of a carer; and health care factors such as late diagnosis, delayed access to care, and mismanagement in care. Four themes were organised into two domains with the first exploring the individual and social circumstances of people with schizophrenia, including the challenges they experience in the health care system. The second domain covers themes that discuss barriers and facilitators to people with schizophrenia receiving palliative care and key features in palliative care provision, including recognising declining health, communication and planning, and collaboration and capacity building in the broader health, mental health and palliative care sectors.

Conclusions

To ensure people with schizophrenia are well supported at the end of life a model of palliative care is required that offers both specialised services and capacity building within the pre-existing health workforce. Resources are needed to address the stigma and lack of services faced by this vulnerable group.

Exploring the Wnt signaling pathway in schizophrenia and bipolar disorder

The Wnt signaling pathway plays a crucial role in neurodevelopment and in regulating the function and structure of the adult nervous system. Schizophrenia (SCZ) and bipolar disorder (BD) are severe mental disorders with evidence of subtle neurodevelopmental, structural and functional neuronal abnormalities. We aimed to elucidate the role of aberrant regulation of the Wnt system in these disorders by evaluating plasma levels of secreted Wnt modulators in patients (SCZ = 551 and BD = 246) and healthy controls (HCs = 639) using enzyme immune-assay. We also investigated the expression of 141 Wnt-related genes in whole blood in a subsample (SCZ = 338, BD = 241, and HCs = 263) using microarray analysis. Both SCZ and BD had dysregulated mRNA expression of Wnt-related genes favoring attenuated canonical (beta-catenin-dependent) signaling, and there were also indices of enhanced non-canonical Wnt signaling. In particular, FZD7, which may activate all Wnt pathways, but favors non-canonical signaling, and NFATc3, a downstream transcription factor and readout of the non-canonical Wnt/Ca²⁺ pathway, were significantly increased in SCZ and BD (p < 3 × 10^-4). Furthermore, patients had lower plasma levels of soluble dickkopf 1 and sclerostin (p < 0.01) compared with HC. Our findings suggest that SCZ and BD are characterized by abnormal Wnt gene expression and plasma protein levels, and we propose that drugs targeting the Wnt pathway may have a role in the treatment of severe mental disorders.

Embracing Psychosis: A Cognitive Insight Intervention Improves Personal Narratives and Meaning-Making in Patients With Schizophrenia

Schizophrenia is a complex psychiatric disorder with unknown and presumably heterogeneous etiology. While the disorder can have various outcomes, research is predominantly "deficit-oriented" emphasizing the hardship that the disorder inflicts on sufferers as well as their families and society. Beyond symptom reduction, imparting patients with hope and meaning in life is increasingly considered an important treatment target, which may raise self-esteem, and reduce self-stigma and suicidal ideation. The present study compared a psychotherapeutic treatment aimed at improving cognitive insight, individualized metacognitive intervention (MCT+), with an active control in order to elucidate if personal meaning-making and hope can be improved in patients with psychosis across time. A total of 92 patients were randomized to either individualized metacognitive therapy (MCT+) or CogPack (neuropsychological training) and followed up for up to 6 months. The "Subjective Sense in Psychosis Questionnaire" (SUSE) was administered which covers different salutogenetic vs pathogenetic views of the disorder, valence of symptom experiences and the consequences of psychosis. Patients in the MCT+ group showed a significant positive shift in attitudes towards the consequences of their illness over time relative to patients in the active control condition. There was some evidence that MCT+ also enhanced meaning-making. The perceived negative consequences of psychosis were highly correlated with depression and low self-esteem, as well as suicidality. The study shows that a cognitive insight training can improve meaning-making in patients and help them come to terms with their diagnosis.

Quantifying the treatment goals of people recently diagnosed with schizophrenia using best-worst scaling

OBJECTIVE

This study seeks to quantify the treatment goals of people recently diagnosed with schizophrenia and explore their impact on treatment plan.

METHODS

People aged 18-35 years with a confirmed diagnosis of schizophrenia within the past 5 years were surveyed in the UK, Germany, and Italy. Treatment goals were assessed via a validated best-worst scaling instrument, where participants evaluated subsets of 13 possible treatment goals identified using a balanced incomplete block design. Participants identified the most and least important goals within each task. Data were also collected on current treatment and preference for daily oral versus long-acting injectable (LAI) treatment. Hierarchical Bayes was used to identify preference weights for the goals, and latent class analysis was used to identify segments of people with similar goals. The segments were compared with the current treatment and preference for oral versus LAI treatment.

RESULTS

Across 100 participants, the average age was 26 years, 75% were male and 50% were diagnosed within 2 years ago. Overall, preferences were most favorable for reduced disease symptoms, think clearly, reduced hospitalizations, reduced anxiety, and take care of self. A total of 61% preferred oral medication and 39% LAI. Two groups were identified with different treatment goals; 50% of participants emphasized clinical goals, including reduced disease symptoms (preference weight =19.7%), reduced hospitalizations (15.5%), and reduced anxiety (10.5%). The other 50% emphasized functional goals, including improved relationships with family/friends (11.4%), increased interest in work (10.6%), experiencing a fuller range of emotions (8.4%), and ability to socialize (7.5%). Those emphasizing functional goals were more likely to be on LAI (44% versus 26%; p=0.059) and preferred LAI (46% versus 32%; p=0.151).

CONCLUSIONS

People with recent-onset schizophrenia may focus more on clinical goals or functional goals, a discussion of which may help facilitate patient engagement.

Efficacy and safety profile of paliperidone palmitate injections in the management of patients with schizophrenia: an evidence-based review

The course of schizophrenia is characterized by multiple relapses, incomplete remission of symptoms, enduring cognitive deficits, and social and occupational functional impairments. Nonadherence to antipsychotic medication is a major determinant of this poor outcome. Long-acting injectable antipsychotics were developed specifically to address the nonadherence problem and are increasingly considered as an early treatment option, in an attempt to prevent accruing morbidity. This review focuses on paliperidone palmitate, the long-acting injectable (LAI) formulation of paliperidone. After considering the pharmacology of paliperidone palmitate, we review the randomized controlled trials, as well as pertinent observational, pragmatic studies for paliperidone once-monthly injections in schizophrenia. Finally, we review the recently introduced 3-monthly formulation of paliperidone palmitate. Taken together, the studies indicate that paliperidone palmitate (PP) has good efficacy compared with placebo and comparable with other antipsychotics including risperidone. The tolerability profile of PP is similar to that of risperidone, with the most important side effects being prolactin elevation, weight gain, and extrapyramidal symptoms. Advantages of PP include the extensive research database and clinical experience with paliperidone and its parent compound risperidone, the availability of different LAI formulations (once-monthly, 3-monthly, and perhaps even longer acting formulations in future), and the novel dose initiation procedure that provides rapid onset of action without the need for oral antipsychotic supplementation.

Low level of knowledge regarding diagnosis and treatment among inpatients with schizophrenia in Shanghai

OBJECTIVE

The study was designed to measure the level of knowledge of the diagnosis of illness and its treatment among patients with schizophrenia in China, and to examine the association between the capacity to provide informed consent and participation in treatment.

PARTICIPANTS AND METHODS

A cross-sectional study was conducted at three clinical inpatient sites in Shanghai, China, during 2015. Patients' knowledge of the illness, as well as the knowledge of the patients' families and psychiatrists, was determined. Logistic regression was used to determine the factors associated with patients' knowledge of schizophrenia.

RESULTS

Out of 109 enrolled schizophrenic inpatients (mean age 42.46±1.29 years), 60.6% were aware of their diagnosis and 67.0% knew details of their treatment plan. The group with unimpaired capacity for giving informed consent had a greater knowledge of their diagnosis (χ²=5.002, p=0.038) and of their treatment plan (χ²=11.196, p<0.01) in comparison with patients who were regarded to be impaired. Using logistic regression analysis, it was found that patients' capacity to give informed consent to treatment was associated with the level of knowledge surrounding the diagnosis (odds ratio =3.230, p<0.05) and the level of knowledge of treatment (odds ratio =4.962, p<0.01).

CONCLUSION

The level of knowledge reported by inpatients with schizophrenia was low with respect to the diagnosis of schizophrenia and of the treatment associated with this illness. An association between patients' capacities for giving informed consent and knowledge of their illness was confirmed in the present study. The results suggest that, in clinical practice, the informed consent process should be strengthened to protect the interests of patients with schizophrenia.

Long-lasting extrapyramidal symptoms after multiple injections of paliperidone palmitate to treat schizophrenia

PURPOSE

Antipsychotic drug treatment can potentially lead to adverse events such as extrapyramidal symptoms (EPSs). If these events persist, they lower patient quality of life. The purpose of this report is to present our experience with such a case, as an example to encourage further study.

PATIENTS AND METHODS

The patient was a 64-year-old male who had been diagnosed with schizophrenia that had been treated with oral antipsychotics for over 40 years. Due to lack of compliance, he was treated with the long-acting injectable antipsychotic, paliperidone palmitate, but developed persistent EPSs after 6 months. He was subsequently treated and monitored in our inpatient facility.

RESULTS

Antipsychotic treatment was stopped. After 6 weeks, the patient's psychosis had worsened, but his EPSs remained unchanged. Levodopa treatment was then started (up to 400 mg/d), which improved his EPSs, so he was restarted on oral antipsychotic therapy (aripiprazole, 6-18 mg/d). His psychotic symptoms improved over 2 months. The improvements in both psychosis and EPSs remained stable. Dopamine transporter scans revealed moderate dopamine transporter loss in the striatum, and computed tomography revealed no sign of brain abnormalities, suggesting that the patient was susceptible to dopamine reductions.

CONCLUSION

Paliperidone palmitate can induce EPSs, even if injected only a few times. Although the characteristics of the drug are potential causes, the patient's predisposition to dopamine perturbations can also influence the outcome. Therefore, adequate awareness is required before injection.

Improving outcomes of first-episode psychosis: an overview

Outcomes of psychotic disorders are associated with high personal, familiar, societal and clinical burden. There is thus an urgent clinical and societal need for improving those outcomes. Recent advances in research knowledge have opened new opportunities for ameliorating outcomes of psychosis during its early clinical stages. This paper critically reviews these opportunities, summarizing the state-of-the-art knowledge and focusing on recent discoveries and future avenues for first episode research and clinical interventions. Candidate targets for primary universal prevention of psychosis at the population level are discussed. Potentials offered by primary selective prevention in asymptomatic subgroups (stage 0) are presented. Achievements of primary selected prevention in individuals at clinical high risk for psychosis (stage 1) are summarized, along with challenges and limitations of its implementation in clinical practice. Early intervention and secondary prevention strategies at the time of a first episode of psychosis (stage 2) are critically discussed, with a particular focus on minimizing the duration of untreated psychosis, improving treatment response, increasing patients' satisfaction with treatment, reducing illicit substance abuse and preventing relapses. Early intervention and tertiary prevention strategies at the time of an incomplete recovery (stage 3) are further discussed, in particular with respect to addressing treatment resistance, improving well-being and social skills with reduction of burden on the family, treatment of comorbid substance use, and prevention of multiple relapses and disease progression. In conclusion, to improve outcomes of a complex, heterogeneous syndrome such as psychosis, it is necessary to globally adopt complex models integrating a clinical staging framework and coordinated specialty care programmes that offer pre-emptive interventions to high-risk groups identified across the early stages of the disorder. Only a systematic implementation of these models of care in the national health care systems will render these strategies accessible to the 23 million people worldwide suffering from the most severe psychiatric disorders.

Internet use, eHealth literacy and attitudes toward computer/internet among people with schizophrenia spectrum disorders: a cross-sectional study in two distant European regions

BACKGROUND

Individuals with schizophrenia spectrum disorders use the Internet for general and health-related purposes. Their ability to find, understand, and apply the health information they acquire online in order to make appropriate health decisions - known as eHealth literacy - has never been investigated. The European agenda strives to limit health inequalities and enhance mental health literacy. Nevertheless, each European member state varies in levels of Internet use and online health information-seeking. This study aimed to examine computer/Internet use for general and health-related purposes, eHealth literacy, and attitudes toward computer/Internet among adults with schizophrenia spectrum disorders from two distant European regions.

METHODS

Data were collected from mental health services of psychiatric clinics in Finland (FI) and Greece (GR). A total of 229 patients (FI = 128, GR = 101) participated in the questionnaire survey. The data analysis included evaluation of frequencies and group comparisons with multiple linear and logistic regression models.

RESULTS

The majority of Finnish participants were current Internet users (FI = 111, 87%, vs. GR = 33, 33%, P < .0001), while the majority of Greek participants had never used computers/Internet, mostly due to their perception that they do not need it. In both countries, more than half of Internet users used the Internet for health-related purposes (FI = 61, 55%, vs. GR = 20, 61%). The eHealth literacy of Internet users (previous and current Internet users) was found significantly higher in the Finnish group (FI: Mean = 27.05, SD 5.36; GR: Mean = 23.15, SD = 7.23, P < .0001) upon comparison with their Greek counterparts. For current Internet users, Internet use patterns were significantly different between country groups. When adjusting for gender, age, education and disease duration, country was a significant predictor of frequency of Internet use, eHealth literacy and Interest. The Finnish group of Internet users scored higher in eHealth literacy, while the Greek group of never Internet users had a higher Interest in computer/Internet.

CONCLUSIONS

eHealth literacy is either moderate (Finnish group) or low (Greek group). Thus, exposure to ICT and eHealth skills training are needed for this population. Recommendations to improve the eHealth literacy and access to health information among these individuals are provided.