Biological predictors of 1-year outcome in schizophrenia in males and females

What happens after early intervention in first-episode psychosis? Limitations of existing service models and an agenda for the future

PURPOSE OF REVIEW

Early intervention in first-episode psychosis (FEP) improves symptomatic and functional outcomes while programs last. However, these gains may not be sustained over time and not all individuals benefit equally from such programs. This review examines the efficacy of FEP programs, as well as step-down practices and long-term outcomes to identify ways to extend the gains made in FEP programs.

RECENT FINDINGS

FEP programs improve outcomes while services last, but effects diminish over time. Step-down and discharge practices vary widely with little randomized evidence guiding practice. Extending the duration of FEP programs for all does not consistently improve outcomes, but there is some encouraging evidence that targeted psychosocial interventions after program end may extend symptomatic and functional benefits. Members of marginalized groups and individuals with poorer outcomes during the FEP period may benefit from further specialized intervention after FEP.

SUMMARY

Step down practices from FEP programs should be structured and tailored to individual needs, and benefit from sustained connections to community resources. Psychosocial interventions like social skills training, peer support, and supported education and employment may help extend the benefit of FEP programs after more intensive services end.

Physical Activity, Sleep-related Behaviors and Severity of Symptoms in Schizophrenia

The beneficial effects of a healthy sleep hygiene and regular physical activity have both been noted in improving psychopathology symptom severity. No study to date however, has evaluated the potential therapeutic effects of both sleep and exercise simultaneously in individuals diagnosed with schizophrenia. To examine the two variables concurrently, in the present report, patients with diagnoses of schizophrenia spectrum disorders (n = 64), were administered assessments that measured both their physical activity and sleep-related behaviors. Additionally, patients' symptom severity and cognitive and daily functioning abilities were also assessed. It was found sleep hygiene and physical activity were associated with patients' symptom severity and cognitive capacities, but not with their daily functioning abilities. Further, no interaction effects were found between sleep hygiene and physical activity. These results suggest that physical activity and sleep hygiene should be considered, independently, in their contribution to psychopathology.

Troubles psychotiques et troubles du sommeil : revue de la littérature

Contexte La disparition de la nomenclature des troubles du sommeil dits primaires ou secondaires, rendue obsolète par le Manuel diagnostique et statistique des troubles mentaux (DSM-5), représente bien l’engouement académique actuel pour ce domaine de recherche. Il est de plus en plus reconnu que les troubles du sommeil sont plus que de simples conséquences d’un trouble psychiatrique et qu’ils peuvent persister malgré un traitement adéquat de la condition comorbide et même précéder ou exacerber cette dernière. Les troubles du sommeil dans les troubles psychotiques, très fréquents, sont donc devenus un sujet d’actualité, représentant une cible d’intervention jusqu’ici sous-estimée.

Objectif Cet article vise à présenter l’état des connaissances actuelles sur la relation entre les troubles du sommeil et les troubles psychotiques ainsi que sur l’utilisation de la thérapie cognitivo-comportementale (TCC) pour traiter les troubles du sommeil dans ce contexte.

Méthode L’article fait une recension narrative de la littérature pour décrire la relation bidirectionnelle entre la psychose et les troubles du sommeil, les corrélations cliniques et les traitements ciblant l’insomnie chez les patients psychotiques.

Résultats Malgré la présence d’une relation entre les troubles du sommeil et les troubles psychotiques, les mécanismes neuronaux, hormonaux et socioculturels régissant cette relation demeurent encore incertains. Bien que l’association reliant les troubles du sommeil et les troubles psychotiques demeure à clarifier, les études démontrent qu’elle serait bidirectionnelle et peut engendrer un cercle vicieux où ces deux composantes s’aggravent mutuellement. Dans ce contexte de comorbidités, les modèles unifiés en TCC deviennent un traitement de choix, à condition d’adapter les protocoles de TCC pour insomnie (TCC-i) à une population avec trouble psychotique (TCC-ip).

Conclusion Malgré la complexité de la relation entre les troubles psychotiques et ceux du sommeil, la TCC-i a été démontrée efficace pour traiter les troubles du sommeil dans une population psychotique et pourrait, dans certains cas, permettre d’alléger la symptomatologie psychotique. De futures études sur ce domaine pourraient permettre le développement de protocoles de thérapie cognitivo-comportementale pour les troubles du sommeil mieux adaptés à la population avec troubles psychotiques.

Neuromodulation of sleep rhythms in schizophrenia: Towards the rational design of non-invasive brain stimulation

Brain function critically depends on oscillatory synchronization of neuronal populations both during wake and sleep. Originally, neural oscillations have been discounted as an epiphenomenon. More recently, specific deficits in the structure of brain oscillations have been linked to psychiatric diseases. For example, schizophrenia is hallmarked by abnormalities in different brain oscillations. Key sleep rhythms during NEM sleep such as sleep spindles, which are implicated in memory consolidation and are related to cognitive functions, are strongly diminished in these patients compared to healthy controls. To date, it remains unclear whether these reductions in sleep oscillations are causal for the functional impairments observed in schizophrenia. The application of non-invasive brain stimulation permits the causal examination of brain network dynamics and will help to establish the causal association of sleep oscillations and symptoms of schizophrenia. To accomplish this, stimulation paradigms that selectively engage specific network targets such as sleep spindles or slow waves are needed. We propose that the successful development and application of these non-invasive brain stimulation approaches will require rational design that takes network dynamics and neuroanatomical information into account. The purpose of this article is to prepare the grounds for the next steps towards such rational design of non-invasive stimulation, with a special focus on electrical and auditory stimulation. First, we briefly summarize the deficits in network dynamics during sleep in schizophrenia. Then, we discuss today's and tomorrow's non-invasive brain stimulation modalities to engage these network targets.

Sleep, circadian rhythms and health

At the core of human thought, for the majority of individuals in the developed nations at least, there is the tacit assumption that as a species we are unfettered by the demands imposed by our biology and that we can do what we want, at whatever time we choose, whereas in reality every aspect of our physiology and behaviour is constrained by a 24 h beat arising from deep within our evolution. Our daily circadian rhythms and sleep/wake cycle allow us to function optimally in a dynamic world, adjusting our biology to the demands imposed by the day/night cycle. The themes developed in this review focus upon the growing realization that we ignore the circadian and sleep systems at our peril, and this paper considers the mechanisms that generate and regulate circadian and sleep systems; what happens mechanistically when these systems collapse as a result of societal pressures and disease; how sleep disruption and stress are linked; why sleep disruption and mental illness invariably occur together; and how individuals and employers can attempt to mitigate some of the problems associated with working against our internal temporal biology. While some of the health costs of sleep disruption can be reduced, in the short-term at least, there will always be significant negative consequences associated with shift work and sleep loss. With this in mind, society needs to address this issue and decide when the consequences of sleep disruption are justified in the workplace.

Slow-wave sleep predicts long-term social functioning in severe mental illness

Sleep's relevance for long-term social functioning in psychiatric disorders has been widely overlooked so far. Here, we investigate social functioning in a transdiagnostic sample of 31 patients with severe mental illness, namely schizophrenia (n = 15) or major depression (n = 16), in relation to their polysomnographic sleep characteristics 6 (± 2.4) years earlier. In addition, cognitive performance at follow-up and clinical characteristics (i.e., severity of disorder-related symptoms and number of hospitalizations between baseline and follow-up) are assessed. Multiple regression analysis results in a model with slow-wave sleep (SWS) and number of hospitalizations as significant predictors accounting for 50% (R2 = 0.507; p <0.001) of the variance in social functioning. SWS remains a significant predictor of long-term social functioning throughout a series of refining analyses which also identify baseline functioning as an additional significant predictor, whereas diagnosis is non-significant. Also, the effect of SWS on social functioning is not mediated by number of hospitalizations as assessed by a bootstrapped mediation analysis. We thus conclude that duration of slow-wave sleep is a powerful predictor of long-term social outcome in psychiatric disorders. Also, we discuss the relevance of verbal memory, symptom severity, and diagnostic category for social functioning. Future studies should test this finding by using a prospective design, a bigger sample, optimized predictor variables, and a more diverse set of diagnoses. Moreover, it should be explored whether or not treating sleep disturbances in psychiatric illnesses independently improves long-term social functioning.

Effect of Olanzapine on Clinical and Polysomnography Profiles in Patients with Schizophrenia

Acute and short-term administration of olanzapine has a favorable effect on sleep in schizophrenia patients. This study aimed to clarify the effect of olanzapine on polysomnographic profiles of schizophrenia patients during the acute phase of illness after controlling for previous drug exposure. Twenty-five drug-naïve or drug-free schizophrenia patients were assessed at baseline and after six weeks of olanzapine treatment on Brief Psychiatric Rating Scale (BPRS), Positive and Negative Syndrome Scale (PANSS), and Udvalg for Kliniske Undersogelser (UKU) side-effect rating scale and a whole-night polysomnography; fifteen patients completed the study. There was a significant reduction in all psychopathological variables with maximum reduction in PANSS total, BPRS total, and PANSS positive scores. A significant increase in total sleep time (TST), sleep efficiency (SE), nonrapid eye movement (NREM) stage 1 duration, stage 3 duration, stage 4 duration, and stage 4 percentage of TST, number of rapid eye movement (REM) periods, REM duration, and REM percentage of TST was observed. REM latency at baseline inversely predicted the reduction in BPRS total and PANSS total and positive scores. In summary, short-term treatment with olanzapine produced significant improvement in clinical and polysomnography profiles of patients with schizophrenia with shorter REM latency predicting a good clinical response.

Reduced Sleep Spindles in Schizophrenia: A Treatable Endophenotype That Links Risk Genes to Impaired Cognition?

Although schizophrenia (SZ) is defined by waking phenomena, abnormal sleep is a common feature. In particular, there is accumulating evidence of a sleep spindle deficit. Sleep spindles, a defining thalamocortical oscillation of non-rapid eye movement stage 2 sleep, correlate with IQ and are thought to promote long-term potentiation and enhance memory consolidation. We review evidence that reduced spindle activity in SZ is an endophenotype that impairs sleep-dependent memory consolidation, contributes to symptoms, and is a novel treatment biomarker. Studies showing that spindles can be pharmacologically enhanced in SZ and that increasing spindles improves memory in healthy individuals suggest that treating spindle deficits in patients with SZ may improve cognition. Spindle activity is highly heritable, and recent large-scale genome-wide association studies have identified SZ risk genes that may contribute to spindle deficits and illuminate their mechanisms. For example, the SZ risk gene CACNA1I encodes a calcium channel that is abundantly expressed in the thalamic spindle generator and plays a critical role in spindle activity based on a mouse knockout. Future genetic studies of animals and humans can delineate the role of this and other genes in spindles. Such cross-disciplinary research, by forging empirical links in causal chains from risk genes to proteins and cellular functions to endophenotypes, cognitive impairments, symptoms, and diagnosis, has the potential to advance the mechanistic understanding, treatment, and prevention of SZ. This review highlights the importance of deficient sleep-dependent memory consolidation among the cognitive deficits of SZ and implicates reduced sleep spindles as a potentially treatable mechanism.

Sleep Disturbances in Schizophrenia

Sleep disturbances are prevalent in patients with schizophrenia and play a critical role in the morbidity and mortality associated with the illness. Subjective and objective assessments of sleep in patients with schizophrenia have identified certain consistent findings. Findings related to the sleep structure abnormalities have shown correlations with important clinical aspects of the illness. Disruption of specific neurotransmitter systems and dysregulation of clock genes may play a role in the pathophysiology of schizophrenia-related sleep disturbances. Antipsychotic medications play an important role in the treatment of sleep disturbances in these patients and have an impact on their sleep structure.

The impact of eszopiclone on sleep and cognition in patients with schizophrenia and insomnia: a double-blind, randomized, placebo-controlled trial

BACKGROUND

Insomnia is frequent in schizophrenia and may contribute to cognitive impairment as well as overuse of weight inducing sedative antipsychotics. We investigated the effects of eszopiclone on sleep and cognition for patients with schizophrenia-related insomnia in a double-blind placebo controlled study, followed by a two-week, single-blind placebo phase.

METHODS

Thirty-nine clinically stable outpatients with schizophrenia or schizoaffective disorder and insomnia were randomized to either 3mg eszopiclone (n=20) or placebo (n=19). Primary outcome measure was change in Insomnia Severity Index (ISI) over 8 weeks. Secondary outcome measure was change in MATRICS Consensus Cognitive Battery (MATRICS). Sleep diaries, psychiatric symptoms, and quality of life were also monitored.

RESULTS

ISI significantly improved more in eszopiclone (mean=-10.7, 95% CI=-13.2; -8.2) than in placebo (mean=-6.9, 95% CI=-9.5; -4.3) with a between-group difference of -3.8 (95% CI=-7.5; -0.2). MATRICS score change did not differ between groups. On further analysis there was a significant improvement in the working memory test, letter-number span component of MATRICS (mean=9.8±9.2, z=-2.00, p=0.045) only for subjects with schizophrenia on eszopiclone. There were improvements in sleep diary items in both groups with no between-group differences. Psychiatric symptoms remained stable. Discontinuation rates were similar. Sleep remained improved during single-blind placebo phase after eszopiclone was stopped, but the working memory improvement in patients with schizophrenia was not durable.

CONCLUSIONS

Eszopiclone stands as a safe and effective alternative for the treatment of insomnia in patients with schizophrenia. Its effects on cognition require further study.

Insomnia comorbid to severe psychiatric illness

In psychiatric illness, there is a growing body of evidence indicating that sleep disturbances exert a detrimental influence on the course of these disorders and contribute to impaired function. Even when psychiatric disorders are successfully treated or stabilized, insomnia and other sleep disturbances often fail to remit. The present review focuses on sleep in two severe mental illnesses, namely bipolar disorder and schizophrenia. This article discusses the role of sleep disturbances and altered sleep architecture in relation to symptom status, functional impairment, quality of life, and the course of these disorders. Current evidence regarding pharmacological and psychological treatment approaches for insomnia in these populations is presented. This review also notes considerations for adapting Cognitive Behavioral Therapy for insomnia (CBT-I) procedures for severe mental illness and proposes directions for future research.

Evaluating the links between schizophrenia and sleep and circadian rhythm disruption

Sleep and circadian rhythm disruption (SCRD) and schizophrenia are often co-morbid. Here, we propose that the co-morbidity of these disorders stems from the involvement of common brain mechanisms. We summarise recent clinical evidence that supports this hypothesis, including the observation that the treatment of SCRD leads to improvements in both the sleep quality and psychiatric symptoms of schizophrenia patients. Moreover, many SCRD-associated pathologies, such as impaired cognitive performance, are routinely observed in schizophrenia. We suggest that these associations can be explored at a mechanistic level by using animal models. Specifically, we predict that SCRD should be observed in schizophrenia-relevant mouse models. There is a rapidly accumulating body of evidence which supports this prediction, as summarised in this review. In light of these emerging data, we highlight other models which warrant investigation, and address the potential challenges associated with modelling schizophrenia and SCRD in rodents. Our view is that an understanding of the mechanistic overlap between SCRD and schizophrenia will ultimately lead to novel treatment approaches, which will not only ameliorate SCRD in schizophrenia patients, but also will improve their broader health problems and overall quality of life.

Insomnia is frequent in schizophrenia and associated with night eating and obesity

BACKGROUND

Sleep difficulties are common in schizophrenia, however these complaints are often overshadowed by more prominent clinical concerns. The point prevalence of insomnia in this population is not well documented. Poor sleep is associated with lower quality of life, impaired cognition, and weight gain.

OBJECTIVES

The objectives of this study are to evaluate the prevalence of insomnia in schizophrenia and to explore the relationship of sleep to cognition, quality of life, and clinical variables.

METHOD

175 outpatients with schizophrenia or schizoaffective disorder were assessed for insomnia. Participants were evaluated for sleep difficulties, sleep patterns, body mass index, and psychiatric symptoms. Participants were also administered a brief cognitive assessment of processing speed.

RESULTS

44% of the sample currently met the criteria for clinical insomnia. An additional 4% were successfully treated with medications. Insomnia was associated with depression and was an independent predictor of lower quality of life. Insomnia was also associated with high rates of night eating and patients with severe insomnia were significantly more obese. The type of antipsychotic did not account for the difference in body mass index. No difference between group means in cognition was detected, although those with severe insomnia did perform least well.

CONCLUSION

Clinical insomnia in outpatients with schizophrenia is highly prevalent and has a negative impact on quality of life and psychiatric symptoms. This study offers additional support to the association between poor sleep and higher weight, as well as indicating a potential link to night eating in this population. Assessment for sleep difficulties should be a routine part of clinical care.

Study factors influencing ventricular enlargement in schizophrenia: a 20 year follow-up meta-analysis

A meta-analysis was performed on studies employing the ventricular-brain ratio to compare schizophrenic subjects to that of normal controls. This was a follow-up to a similar meta-analysis published in 1992 in which study-, in addition to clinical-, factors were found to contribute significantly to the reported difference between patients with schizophrenia and controls. Seventy-two (N=72) total studies were identified from the peer reviewed literature, 39 from the original meta-analysis, and 33 additional studies published since which met strict criteria for inclusion and analysis - thus representing ~30 years of schizophrenia ventricular enlargement research. Sample characteristics from schizophrenics and controls were coded for use as predictor variables against within sample VBR values as well as for between sample VBR differences. Additionally, a number of factors concerning how the studies were conducted and reported were also coded. Obtained data was subjected to unweighted univariate as well as multiple regression analyses. In particular, results indicated significant differences between schizophrenics and controls in ventricular size but also the influence of the diagnostic criteria used to define schizophrenia on the magnitude of the reported VBR. This suggests that differing factors of the diagnostic criteria may be sensitive to ventricular enlargement and might be worthy of further examination. Interestingly, we observed an inverse relationship between VBR difference and the number of co-authors on the study. This latter finding suggests that larger research groups report smaller VBR differences and may be more conservative or exacting in their research methodology. Analyses weighted by sample size provided identical conclusions. The effects of study factors such as these are helpful for understanding the variation in the size of the reported differences in VBR between patients and controls as well as for understanding the evolution of research on complex clinical syndromes employing neuroimaging morphometrics.

Reduced overnight consolidation of procedural learning in chronic medicated schizophrenia is related to specific sleep stages

We previously reported that patients with schizophrenia failed to demonstrate normal sleep-dependent improvement in motor procedural learning. Here, we tested whether this failure was associated with the duration of Stage 2 sleep in the last quartile of the night (S2q4) and with spindle activity during this epoch. Fourteen patients with schizophrenia and 15 demographically matched controls performed a motor sequence task (MST) before and after a night of polysomnographically monitored sleep. Patients showed no significant overnight task improvement and significantly less than controls, who did show significant improvement. While there were no group differences in overall sleep architecture, patients showed significant reductions in fast sigma frequency power (45%) and in spindle density (43%) during S2q4 sleep at the electrode proximal to the motor cortex controlling the hand that performed the MST. Although spindle activity did not correlate with overnight improvement in either group, S2q4 sleep duration in patients significantly correlated with the plateau level of overnight improvement seen at the end of the morning testing session, and slow wave sleep (SWS) duration correlated with the delay in reaching this plateau. SWS and S2q4 sleep each predicted the initial level of overnight improvement in schizophrenia, and their product explained 77% of the variance, suggesting that both sleep stages are necessary for consolidation. These findings replicate our prior observation of reduced sleep-dependent consolidation of motor procedural learning in schizophrenia and link this deficit to specific sleep stages. They provide further evidence that sleep is an important contributor to cognitive deficits in schizophrenia.

Does abnormal sleep impair memory consolidation in schizophrenia?

Although disturbed sleep is a prominent feature of schizophrenia, its relation to the pathophysiology, signs, and symptoms of schizophrenia remains poorly understood. Sleep disturbances are well known to impair cognition in healthy individuals. Yet, in spite of its ubiquity in schizophrenia, abnormal sleep has generally been overlooked as a potential contributor to cognitive deficits. Amelioration of cognitive deficits is a current priority of the schizophrenia research community, but most efforts to define, characterize, and quantify cognitive deficits focus on cross-sectional measures. While this approach provides a valid snapshot of function, there is now overwhelming evidence that critical aspects of learning and memory consolidation happen offline, both over time and with sleep. Initial memory encoding is followed by a prolonged period of consolidation, integration, and reorganization, that continues over days or even years. Much of this evolution of memories is mediated by sleep. This article briefly reviews (i) what is known about abnormal sleep in schizophrenia, (ii) sleep-dependent memory consolidation in healthy individuals, (iii) recent findings of impaired sleep-dependent memory consolidation in schizophrenia, and (iv) implications of impaired sleep-dependent memory consolidation in schizophrenia. This literature suggests that abnormal sleep in schizophrenia disrupts attention and impairs sleep-dependent memory consolidation and task automation. We conclude that these sleep-dependent impairments may contribute substantially to generalized cognitive deficits in schizophrenia. Understanding this contribution may open new avenues to ameliorating cognitive dysfunction and thereby improve outcome in schizophrenia.

Effects of antipsychotic medications on sleep in schizophrenia

Schizophrenia is often accompanied by sleep problems. Evidence exists that these sleep difficulties have significant effects on individuals with this disorder. The mainstay of treatment for this condition is the administration of medications that have effects on neurotransmitter systems, which play an important role in sleep-wake function, including histamine, acetylcholine, serotonin, norepinephrine and dopamine. Little systematic attention, however, has been paid to how the sleep effects of these agents might play a role in the course of treatment, function and quality of life of schizophrenia patients. Schizophrenia medications can improve sleep problems and reverse the sleep architectural derangements that are common among patients with schizophrenia and, therefore, have the potential to improve the quality of life and functional capacity of the patient. Conversely, some sleep-wake effects of these medications can impair patient function and quality of life. In this study, we review the effects of schizophrenia medications and discuss their relevance to optimizing the clinical treatment of people with schizophrenia with regard to sleep-wake function.

The neurobiological characteristics of rapid eye movement (REM) sleep are candidate endophenotypes of depression, schizophrenia, mental retardation and dementia

Animal models are a promising method to approach the basic mechanisms of the neurobiological disturbances encountered in mental disorders. Depression is characterized by a decrease of REM sleep latency and an increase of rapid eye movement density. In schizophrenia, electrophysiological, tomographic, pharmacological and neurochemical activities are all encountered during REM sleep. Mental retardation and dementia are characterized by rather specific REM sleep disturbances. Identification of the genetic support for these abnormalities (endophenotypes) encountered during REM sleep could help to develop specific treatments.

Sleep in schizophrenia: impairments, correlates, and treatment

In untreated schizophrenia, psychotic decompensation is associated with profound insomnia, one of the prodromal symptoms associated with psychotic relapse. First- and second-generation antipsychotic medication can ameliorate this insomnia, but side effects may include sedation or residual insomnia. Patients who are clinically stable and medicated may continue to experience disturbed sleep, including long sleep-onset latencies, poor sleep efficiency, slow wave sleep deficits, and short rapid eye movement latencies. Schizophrenia also can be associated with comorbid sleep disorders, which may be enhanced or induced by antipsychotic medication. Sleep disorders in schizophrenia should be treated vigorously because normalized sleep and its restorative processes may be essential for a positive clinical outcome.

Older schizophrenia patients have more disrupted sleep and circadian rhythms than age-matched comparison subjects

Patient reports and laboratory studies suggest schizophrenia patients have disrupted sleep across age groups. Studies have not compared overall sleep/wake patterns or circadian (24-h) activity rhythms of older community dwelling schizophrenia patients to matched comparison subjects. This study examined whether older schizophrenia patients had more disrupted sleep/wake patterns and circadian activity rhythms than age- and gender-matched normal comparison subjects (NCS). Twenty-eight older schizophrenia patients and 28 age- and gender-matched NCS were studied with three days of continuous wrist actigraphy. Nighttime and daytime actigraphically estimated sleep and wake, circadian activity rhythms and light exposure patterns were compared with and without years of education as a covariate. Patients spent longer in bed, had more disrupted nighttime sleep, slept more during the day, and had less robust circadian rhythms of activity and light exposure compared to NCS. Differences persisted in education-adjusted analyses. Within patients, working was associated with improved sleep and circadian rhythms. Findings suggest the sleep and circadian rhythm disruption of older schizophrenia patients was more extensive than that of matched NCS suggesting patients' sleep disruption was above and beyond what is attributable to advanced age alone. A need exists to develop multicomponent interventions to address sleep difficulties specific to older schizophrenia patients.

Initial magnetic resonance imaging volumetric brain measurements and outcome in schizophrenia: a prospective longitudinal study with 5-year follow-up

BACKGROUND

Several demographic and phenomenological variables have been identified as predictors of outcome in schizophrenia. Far fewer studies have examined the relationships between brain morphology assessed at illness onset and subsequent outcome, and their results have been contradictory.

METHODS

The relationships between magnetic resonance imaging (MRI) regional brain volumes at illness onset and outcome five years later were studied in 123 schizophrenia patients using regression and correlation analysis. Outcome measures included psychosocial functioning, weeks per year receiving inpatient treatment, and persistence of severe psychotic, disorganized and negative symptoms.

RESULTS

Temporal lobe tissue volume at onset was predictive of outcome. Smaller temporal lobe gray matter volume (both left and right) was associated with persistence of hallucinations during follow-up. There were no significant associations between hallucinations and temporal white matter, or between delusions and temporal white or gray matter volumes. None of the other volumetric brain measures were predictive of outcome.

CONCLUSIONS

The association between initial temporal lobe gray matter volume and subsequent persistent hallucinations may help identify individuals who are at higher risk for poor outcome and help guide their treatment planning. However, regional brain volumes assessed near illness onset, in general, do not appear to be indicative of subsequent outcome in schizophrenia.

The second-generation 'atypical' antipsychotics: similar improved efficacy but different neuroendocrine side effects

The neuroendocrine aspects of schizophrenia generally receive little attention. This is in marked contrast to depressive disorders, where neuroendocrine issues are central to discussions of pathophysiology and treatment. Although the nature of neuroendocrine dysfunction is less well characterized in schizophrenia than in major depression, a number of neuroendocrine abnormalities have been described. Hypercortisolemia has been extensively documented in patients with schizophrenia, particularly during acute exacerbations, with persistent hypercortisolemia being associated with ventricular enlargement and poor outcome. Similarly, abnormalities in thyroid function, the hypothalamo-pituitary-gonadal axis, growth hormone, prolactin, neurotensin, and other neuroendocrine parameters have also been described in schizophrenia. While the precise neuroendocrine profile of schizophrenia is incompletely characterized, the impact of antipsychotic medications employed in its treatment on various endocrine parameters is better understood. Different conventional and atypical antipsychotics variably contribute to hyperprolactinemia, insulin resistance, and other abnormalities. A critical overview of neuroendocrine abnormalities in schizophrenia is provided and the differential impact of different antipsychotics in contributing to neuroendocrine dysfunction is discussed.

The neurochemistry of waking and sleeping mental activity: the disinhibition-dopamine hypothesis

This paper describes a hypothesis related to the neurochemical background of sleep-waking mental activity which, although associated with subcortical structures, is principally generated in the cerebral cortex. Acetylcholine, which mainly activates cortical neurons, is released at the maximal rate during waking and rapid eye movement (REM) sleep dreaming stage. Its importance in mental functioning is well-known. However, brainstem-generated monoamines, which mainly inhibit cortical neurons, are released during waking. Both kinds of influences contribute to the organized mentation of waking. During slow wave sleep, these two types of influence decrease in intensity but maintain a sufficiently high level to allow mental activity involving fairly abstract pseudo-thoughts, a mode of activity modelled on the diurnal pattern of which it is a poor reply. During REM sleep, the monoaminergic neurons become silent except for the dopaminergic ones. This results in a large disinhibition and the maintained dopamine influence may be involved in the familiar psychotic-like mental activity of dreaming. Indeed, in this original activation-disinhibition state, the increase of dopamine influence at the prefrontal cortex level could explain the almost total absence of negative symptoms of schizophrenia during dreaming, while an increase in the nucleus accumbens is possibly responsible for hallucinations and delusions, which are regular features of mentation during this sleep stage.