Effects of 4 weeks treatment with chlorpromazine and/or trihexyphenidyl on the pituitary-gonadal axis in male paranoid schizophrenics

Sex-specific associations between sex hormones and clinical symptoms in late-life schizophrenia

The prevalence of late-life schizophrenia is increasing with high burden. It is well-documented that schizophrenia affects men and women differently in terms of symptoms. Sex hormones, which play a role in the pathology and symptoms of schizophrenia, are greatly affected by aging. To the best of our knowledge, this is a study to examine the sex differences in psychiatric symptoms and their correlation with sex hormones in participants with late-life schizophrenia. Positive and Negative Syndrome Scale (PANSS) factors were evaluated. Testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, progesterone, and prolactin were measured. Male participants with late-life schizophrenia had more severe negative symptoms than female participants (z = -2.56, P = 0.010), while female participants had more severe anxiety/depression compared to male participants (z = 2.64, P = 0.008). Testosterone levels in male participants were positively associated with negative symptoms (β = 0.23, t = 2.27, P = 0.025), while there was no significant association between sex hormones and symptoms in female participants. In conclusion, higher testosterone levels were associated with more severe negative symptoms in male participants with late-life schizophrenia, suggesting that attention should be paid to the sex differences in late-life schizophrenia in clinical practice.

Schizophrenia and Sex Hormones: What Is the Link?

The involvement of gonadal hormones in the pathogenesis of schizophrenia has long been suspected because the psychosis differs in women and men and the illness first makes its appearance shortly after puberty. Changes in sex hormones have been linked with increased vulnerability to mood disorders in women, while testosterone have been associated with increased sexual drive and aggressiveness in men as well as women. Some studies have found abnormal levels of estrogens and testosterone in schizophrenia patients, but the results have been inconsistent and sometimes attributed to the hyperprolactinemia effect of antipsychotics, which may interfere with sex hormones production. The purpose of this review is to present the current knowledge on the link between blood levels of sex-hormones in women during the various stages of the female reproductive life (i.e. puberty, menstrual cycle, pregnancy, contraception, and menopause) and the course of schizophrenia. We also attempt to optimize the clinical approach to women with schizophrenia at these different stages.

Sex steroids and schizophrenia

The peak in incidence for schizophrenia is during late adolescence for both sexes, but within this time frame the peak is both earlier and steeper for males. Additionally, women have a second peak in incidence following menopause. Two meta-analyses have reported that men have an overall ∼40% greater chance of developing schizophrenia than do women (Aleman et al., 2003; McGrath et al., 2004). These and other findings have led to the suggestion that ovarian hormones may be protective against schizophrenia. Less explored is the potential role of testosterone in schizophrenia, although disruptions in steroid levels have also been reported in men with the illness. The relationship between increased gonadal hormone release per se and peri-adolescent vulnerability for psychiatric illness is difficult to tease apart from other potentially contributory factors in clinical studies, as adolescence is a turbulent period characterized by many social and biological changes. Despite the obvious opportunity provided by animal research, surprisingly little basic science effort has been devoted to this important issue. On the other hand, the animal work offers an understanding of the many ways in which gonadal steroids exert a powerful impact on the brain, both shaping its development and modifying its function during adulthood. Recently, investigators using preclinical models have described a greater male vulnerability to neurodevelopmental insults that are associated with schizophrenia; such studies may provide clinically relevant insights into the role of gonadal steroids in psychiatric illness.

Short-term testosterone augmentation in male schizophrenics: a randomized, double-blind, placebo-controlled trial

Although there are few studies on the treatment of schizophrenia with testosterone, several indirect findings have suggested testosterone as a possible treatment modality for schizophrenia. To explore the therapeutic effect of testosterone augmentation of antipsychotic medication on symptoms in male patients with schizophrenia, the authors performed a placebo-controlled, double-blind trial on 30 schizophrenic men, using either 5 g of 1% testosterone gel (Testogel; Besins Iscovesco, Paris, France) or a placebo added to a fixed dosage of antipsychotic medication over a period of 4 weeks with a 2-week washout period. In addition, to get additional information about the involvement of these reproductive hormones after testosterone augmentation, the authors evaluated several hormones such as total testosterone, free testosterone, dehydroepiandrosterone sulfate, estradiol, and prolactin. Results indicated a significant improvement of negative symptoms in both the last observation carried forward and the completer analyses and a nonsignificant trend for the improvement of depressive symptoms in completers. There were no significant changes in serum hormone levels except total and free testosterone. The findings of this study suggest that testosterone augmentation may be a potential therapeutic strategy in patients with schizophrenia.

Testosterone for schizophrenia

BACKGROUND

Recently, sex hormones such as estrogens and testosterone or its derivatives have been the focus of interest for treatment of persistent symptoms associated with schizophrenia.

OBJECTIVES

To review the effects of dehydroepiandrosterone (DHEA)/testosterone as adjunctive therapy to standard antipsychotic drugs.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group Trials Register (January 2007).

SELECTION CRITERIA

We included all clinical randomised trials comparing DHEA/testosterone plus standard antipsychotic treatment with standard treatment alone.

DATA COLLECTION AND ANALYSIS

We independently selected studies and extracted data. For dichotomous data we calculated the relative risk (RR) and its 95% confidence interval (CI) on an intention to treat basis, using a fixed effects model. We presented continuous data using the weighted mean difference statistic, with a 95% confidence interval using a fixed effects model.

MAIN RESULTS

We found three relevant small, short trials (total n=126). Clinical Global Impression data were equivocal (n=27, 1 RCT, WMD -0.43 CI -0.9 to 0.1). Average total PANSS scores were not significantly different between the DHEA plus antipsychotic group and those given antipsychotic drugs and placebo (n=82, 2 RCTs, WMD -4.16 CI -13.8 to 5.5). PANSS positive scores were equivocal (n=55, 1 RCT, WMD -1.00 CI -3.8 to 1.8). For negative symptoms binary SANS scale data favoured the DHEA plus antipsychotic group (n=30, 1 RCT, RR 0.23 CI 0.1 to 0.6, NNT 2 CI 2 to 3) but PANSS negative scores were not significantly different between comparison groups (n=55, 1 RCT, WMD -2.30 CI -6.4 to 1.8). About 17% of people left both groups early (n=64, 2 RCTs, RR 0.80 CI 0.3 to 2.4). St Hans Rating Scale data for extrapyramidal symptoms favoured the DHEA plus antipsychotic group (n=30, 1 RCT, WMD -5.00 CI -8.8 to -1.2) but akathisia ratings were equivocal (n=34, 1 RCT, RR 2.67 CI 0.3 to 23.1). Ratings of parkinsonian movement disorder differed within the same trial depending of the outcome scale used. Quality of life seemed unaffected by use of DHEA (n=55, 1 RCT, WMD 6.20 CI -1.4 to 13.8).

AUTHORS' CONCLUSIONS

Results are inconclusive with most outcomes being either non-significant or producing contradictory findings. Currently, adjunctive DHEA should remain an experimental treatment for people with schizophrenia.

Mechanisms of osteoporosis in spinal cord injury

Osteoporosis is a known complication of spinal cord injury (SCI), but its mechanism remains unknown. The pathogenesis of osteoporosis after SCI is generally considered disuse. However, although unloading is an important factor in the pathogenesis of osteoporosis after SCI, neural lesion and hormonal changes also seem to be involved in this process. Innervation and neuropeptides play an important role in normal bone remodelling. SCI results in denervation of the sublesional bones and the neural lesion itself may play a pivotal role in the development of osteoporosis after SCI. Although upper limbs are normally loaded and innervated, bone loss also occurs in the upper extremities in patients with paraplegia, indicating that hormonal changes may be associated with osteoporosis after SCI. SCI-mediated hormonal changes may contribute to osteoporosis after SCI by different mechanisms: (1) increased renal elimination and reduced intestinal absorption of calcium leading to a negative calcium balance; (2) vitamin D deficiency plays a role in the pathogenesis of SCI-induced osteoporosis; (3) SCI antagonizes gonadal function and inhibits the osteoanabolic action of sex steroids; (4) hyperleptinaemia after SCI may contribute to the development of osteoporosis; (5) pituitary suppression of TSH may be another contributory factor to bone loss after SCI; and (6) bone loss after SCI may be caused directly, at least in part, by insulin resistance and IGFs. Thus, oversupply of osteoclasts relative to the requirement for bone resorption and/or undersupply of osteoblasts relative to the requirement for cavity repair results in bone loss after SCI. Mechanisms for the osteoporosis following SCI include a range of systems, and osteoporosis after SCI should not be simply considered as disuse osteoporosis. Unloading, neural lesion and hormonal changes after SCI result in severe bone loss. The aim of this review is to improve understanding with regard to the mechanisms of osteoporosis after SCI. The understanding of the pathogenesis of osteoporosis after SCI can help in the consideration of new treatment strategies. Because bone resorption after SCI is very high, intravenous bisphosphonates and denosumab should be considered for the treatment of osteoporosis after SCI.