Considering schizophrenia from a prevention perspective

The other face of advanced paternal age: a scoping review of its terminological, social, public health, psychological, ethical and regulatory aspects

BACKGROUND

There is a global tendency for parents to conceive children later in life. The maternal dimension of the postponement transition has been thoroughly studied, but interest in the paternal side is more recent. For the moment, most literature reviews on the topic have focused on the consequences of advanced paternal age (APA) on fertility, pregnancy and the health of the child.

OBJECTIVE AND RATIONALE

The present review seeks to move the focus away from the biological and medical dimensions of APA and synthesise the knowledge of the other face of APA.

SEARCH METHODS

We used the scoping review methodology. Searches of interdisciplinary articles databases were performed with keywords pertaining to APA and its dimensions outside of biology and medicine. We included scientific articles, original research, essays, commentaries and editorials in the sample. The final sample of 177 documents was analysed with qualitative thematic analysis.

OUTCOMES

We identified six themes highlighting the interdisciplinary nature of APA research. The 'terminological aspects' highlight the lack of consensus on the definition of APA and the strategies developed to offer alternatives. The 'social aspects' focus on the postponement transition towards reproducing later in life and its cultural dimensions. The 'public health aspects' refer to attempts to analyse APA as a problem with wider health and economic implications. The 'psychological aspects' focus on the consequences of APA and older fatherhood on psychological characteristics of the child. The 'ethical aspects' reflect on issues of APA emerging at the intersection of parental autonomy, children's welfare and social responsibility. The 'regulatory aspects' group different suggestions to collectively approach the implications of APA. Our results show that the field of APA is still in the making and that evidence is lacking to fully address the issues of APA. The review suggests promising avenues of research such as introducing the voice of fathers of advanced age into the research agenda.

WIDER IMPLICATIONS

The results of this review will be useful for developing policies and preconception health interventions that consider and include prospective fathers of advanced age.

The Ohio State University Early Psychosis Intervention Center (EPICENTER) step-based care programme for individuals at clinical high risk for psychosis: study protocol for an observational study

INTRODUCTION

In October 2018, the Substance Abuse and Mental Health Services Administration funded 21 sites throughout the USA to develop, implement and evaluate specialised care programmes for individuals at clinical high risk for developing a psychotic disorder (CHR-P). Per the funding requirements, such programmes were required to provide 'step-based care'-a model in which individuals are initially provided with low-intensity, non-psychosis-specific and more benign (ie, least side effects) interventions and only progress onto higher-intensity, psychosis-specific interventions with a greater risk of more severe side effects should they not meet a priori criteria for clinical response to such lower-intensity interventions. Here, we outline the evaluation component of the step-based care programme for individuals at CHR-P at The Ohio State University Early Psychosis Intervention Center (EPICENTER).

METHODS AND ANALYSES

The EPICENTER CHR-P programme provides a step-based care model comprising psychotherapy, medication management, family support/education, peer support and vocational/educational support. All participants who opt to receive care at the EPICENTER will complete a standardised assessment battery as part of usual care. This battery will be administered on enrolment and will be re-administered at 6-month intervals throughout individuals' participation in EPICENTER clinical services. Participants will have the opportunity to allow for data from these usual care assessments to be used as part of an evaluation project for this new clinical service. The primary outcome for this evaluation project is time to remission of symptomatic and functional deficits commonly experienced by individuals at CHR-P. Participants will also have the opportunity to participate in a supplemental research project designed to further evaluate treatment outcomes and patient characteristics among individuals participating in EPICENTER clinical services.

ETHICS AND DISSEMINATION

This project was approved by The Ohio State University Institutional Review Board. Results from this project will be disseminated through publications and presentations.

TRIAL REGISTRATION NUMBER

NCT03970005; Pre-results.

Youth-caregiver agreement on clinical high-risk symptoms of psychosis

Early identification of individuals who will go on to develop schizophrenia is a difficult endeavor. The variety of symptoms experienced by clinical high-risk youth make it difficult to identify who will eventually develop schizophrenia in the future. Efforts are being made, therefore, to more accurately identify at-risk individuals and factors that predict conversion to psychosis. As in most assessments of children and adolescents, however, both youth and parental report of symptomatology and resulting dysfunction are important to assess. The goals of the current study were to assess the extent of cross-informant agreement on the Structured Interview for Prodromal Symptoms (SIPS), a widely-used tool employed to determine clinical high-risk status. A total of 84 youth-caregiver pairs participated. Youth and caregiver raters displayed moderate overall agreement on SIPS-rated symptoms. Both youth and caregiver ratings of youth symptomatology contributed significantly to predicting conversion to psychosis. In addition, youth age and quality of youth-caregiver relationships appear to be related to cross-informant symptom ratings. Despite differences on individual SIPS domains, the majority of dyads agreed on youth clinical high-risk status. Results highlight the potential clinical utility of using caregiver informants to determine youth psychosis risk.

The Prevention of Mental Disorders has a Bright Future

This article takes four looks at the status of prevention in psychiatry. The first glance is critical, shaped by disappointment at the slow progress in the understanding of psychiatric diseases and the lack of promise in prevention. The second look is less humble. It characterizes and acknowledges the efforts made so far. The third and the fourth perspectives optimistically announce a new age in research and prevention. Breakthroughs, whose contours are already appearing on the horizon today, will transform the prevention of psychiatric diseases into a success story within the next 10–15 years.

Early intervention and the treatment of prodrome in schizophrenia: a review of recent developments

OBJECTIVE

Strategies for preventing the development of schizophrenia are in their infancy but are associated with much hope and potential. The relatively long prodrome in schizophrenia allows for indicated prevention as an effective intervention. "High-risk" individuals have subtle symptoms and, without intervention, a third would develop psychosis within 1 year, and many will have poor functional outcomes, even in the absence of psychosis. Research in this area is preliminary but encouraging.

METHODS

A literature search was performed using databases including PubMed, PsychInfo, and Cochrane, as well as a search of individual journals through cross-referencing. The search used the following key words: schizophrenia, psychosis, psychotic disorders, first episode, early, prodrome, prodromal, prevention, ultra high risk, at risk, and intervention.

RESULTS

Strategies for preventing the development of schizophrenia are divided into universal, selective, and indicated levels of prevention. The common preventive methods include treatment with antipsychotic medications and psychotherapy. Early intervention helps at risk individuals with symptom reduction and appears to delay conversion to full blown psychosis. However, the criteria for identifying at risk individuals have low predictive value, which raises concerns about unnecessary and potentially harmful interventions.

CONCLUSION

Although a range of interventions appear to be effective in reducing rates of transition to psychosis, they are inadequately differentiated and require further study. Current data suggest that clinicians take an individualized approach to intervention, considering the risk-benefit ratio on a case-by-case basis.

A systematic meta-review grading the evidence for non-genetic risk factors and putative antecedents of schizophrenia

INTRODUCTION

Identifying the relative strength of evidence associated with non-genetic risk factors and putative antecedents of schizophrenia will guide research and may inform the design of early detection and intervention strategies.

AIMS

To present and quality assess current evidence for non-genetic risk factors and putative antecedents derived from well-conducted systematic reviews that report pooled data.

METHOD

Medline, Embase, CINAHL, Current Contents, and PsycINFO databases were searched systematically, and supplemented by hand searching. Review reporting quality was assessed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, review methodology was assessed using the Assessment of Multiple Systematic Reviews (AMSTAR) checklist, and evidence quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Twenty-four reviews met inclusion criteria. The risk factors with the highest quality evidence, reporting medium effect sizes, were advanced paternal age, obstetric complications, and cannabis use. The strongest evidence among the putative antecedents was identified for motor dysfunction and low IQ.

CONCLUSIONS

More research is required that applies sound methodological practices, taking into consideration specificity for schizophrenia and possible confounding factors, to robustly identify the non-genetic risk factors and putative antecedents of schizophrenia.

DETERMINING THE ASSOCIATION BETWEEN DERMATOGLYPHICS AND SCHIZOPHRENIA BY USING FINGERPRINT ASYMMETRY MEASURES

Early detection and intervention strategies for schizophrenia are receiving increasingly more attention. Dermatoglyphic patterns, such as the degree of asymmetry of the fingerprints, have been hypothesized to be indirect measures for early abnormal developmental processes that can lead to later psychiatric disorders such as schizophrenia. However, previous results have been inconsistent in trying to establish the association between dermatoglyphics and schizophrenia. The goal of this work is to try to resolve this problem by borrowing well-developed techniques from the field of fingerprint matching. Two dermatoglyphic asymmetry measures are proposed that draw on the orientation field of homologous fingers. To test the capability of these measures, fingerprint images were acquired digitally from 40 schizophrenic patients and 51 normal individuals. Based on these images, no statistically significant association between conventional dermatoglyphic asymmetry measures and schizophrenia was found. In contrast, the sample means of the proposed measures consistently identified the patient group as having a higher degree of asymmetry than the control group. These results suggest that the proposed measures are promising for detecting the dermatoglyphic patterns that can differentiate the patient and control groups.

Advanced paternal age is a risk factor for schizophrenia in Iranians

BACKGROUND

Since 1958 many, but not all studies have demonstrated that paternal age is a risk factor for schizophrenia. There may be many different explanations for differences between studies, including study design, sample size, collection criteria, heterogeneity and the confounding effects of environmental factors that can for example perturb epigenetic programming and lead to an increase in disease risk. The small number of children in Western families makes risk comparisons between siblings born at different paternal ages difficult. In contrast, more Eastern families have children both at early and later periods of life. In the present study, a cross-sectional population study in an Iranian population was performed to compare frequency of schizophrenia in younger offspring (that is, older paternal age) versus older offspring.

METHODS

A total of 220 patients with the diagnosis of schizophrenia (cases) from both psychiatric hospitals and private clinics and 220 individuals from other hospital wards (controls), matched for sex and age were recruited for this study. Patients with neurological problem, substance abuse, mental retardation and mood disorder were excluded from both groups.

RESULTS

Birth rank comparisons revealed that 35% vs 24% of the cases vs the controls were in the third or upper birth rank (P = 0.01). Also, the mean age of fathers at birth in case group (30 ± 6.26 years) was significantly more than the control group (26.45 ± 5.64 years; P = 0.0001). The age of 76 fathers at birth in case group was over 32 versus 33 fathers in control group. Individuals whose fathers' age was more than 32 (at birth) were at higher risk (2.77 times) for schizophrenia versus others (P < 0.0001, 95% CI 1.80 to 4.27). The maternal age at parturition of the case versus controls groups was 26.1 ± 5.41 vs 25.07 ± 4.47 (P = 0.02). Logistic regression analysis suggests that maternal age is less likely to be involved in the higher risk of schizophrenia than advanced parental age.

DISCUSSION

This study demonstrates a relationship between paternal age and schizophrenia in large families of an Iranian population. Arguments have been put forth that DNA bases changes or epigenetic changes in sperm account for the increased risk associated with older fathers. However, it would not be surprising that both de novo germline mutations and epigenetic changes contribute to disease occurrence because DNA replication and DNA methylation are closely linked at both the macromolecular level (that is, methylation closely follows replication), and at the metabolic level (both processes require folate), and susceptible to modulation by the environment. Further research on samples such as those collected here are needed to sort out the contributions of de novo mutations versus epigenetic changes to schizophrenia.

Beliefs about causes of schizophrenia among urban African American community members

The public's causal attributions of schizophrenia have far-reaching effects on the community and affected individuals. This study investigated causal beliefs within a community of predominantly Protestant, low-income, urban, African Americans in the southeastern United States. Two hundred eighty-two patrons of an inner-city food court/farmers' market participated in a self-administered survey assessing causal beliefs through a 30-item survey and self-reported causal opinions. Associations were assessed between causal attributions of schizophrenia and sociodemographic characteristics and exposure/familiarity variables. Certain sociodemographic variables, as well as key exposure/familiarity variables, predicted the nature of one's causal beliefs. The most common causal opinions reported included substance abuse, negative life events, and "mental illness." Findings from a subsample administered an exploratory multiple-choice question investigating understanding of causation revealed that the public may not fully understand the nature of causation. Although this study suggests potential determinants of causal beliefs held by community members, further research examining the public's conception of causation would enhance interpretation of studies on such beliefs.

Schizophrenia, "just the facts" 5. Treatment and prevention. Past, present, and future

The introduction of second-generation antipsychotics and cognitive therapies for schizophrenia over the past two decades generated considerable optimism about possibilities for recovery. To what extent have these developments resulted in better outcomes for affected individuals? What is the current state of our science and how might we address the many unmet needs in the prevention and treatment of schizophrenia? We trace the evolution of various treatments for schizophrenia and summarize current knowledge about available pharmacological and psychosocial treatments. We consider the widely prevalent efficacy-effectiveness gap in the application of available treatments and note the significant variability in individual treatment response and outcome. We outline an individualized treatment approach which emphasizes careful monitoring and collaborative decision-making in the context of ongoing benefit-risk assessment. We note that the evolution of both pharmacological and psychosocial treatments thus far has been based principally on serendipity and intuition. In view of our improved understanding of the etiology and pathophysiology of schizophrenia, there is an opportunity to develop prevention strategies and treatments based on this enhanced knowledge. In this context, we discuss potential psychopathological treatment targets and enumerate current pharmacological and psychosocial development efforts directed at them. Considering the stages of schizophrenic illness, we review approaches to prevent progression from the pre-symptomatic high-risk to the prodrome to the initial psychotic phase to chronicity. In view of the heterogeneity of risk factors, we summarize approaches towards targeted prevention. We evaluate the potential contribution of pharmacogenomics and other biological markers in optimizing individual treatment and outcome in the future.

The experiences of carers in Taiwanese culture who have long-term schizophrenia in their families: a phenomenological study

Schizophrenia is a severe illness with little hope of recovery and requires long-term care. The purpose of this study was to explore the experiences of carers who live with someone with long-term schizophrenia, within the cultural context of Taiwan. The study was conducted in a community setting in central Taiwan. A qualitative phenomenological approach was used to explore the experiences of carers. Purposive sampling was used by selecting the carers who were close relatives of the clients, had lived with the clients for at least 1 year and bore most of the responsibilities. Semi-structured face-to-face interviews were conducted to collect the data and narratives were analysed using Colaizzi's (1978) seven-step method. Data saturation was achieved after interviewing 10 carers. Three themes and eight sub-themes were identified: burdens of caring (helping clients' illness, lack of professional support and family conflicts), emotional burdens (sadness, worry and fear) and strategies of coping (cognitive and religious coping strategies). Our study supported the importance for nurses to understand the cultural aspects of mental illness, particularly the widespread cultural beliefs and patterns of help seeking behaviours, in order to provide culturally sensitive health care.

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

The postweaning social isolation in C57BL/6 mice: preferential vulnerability in the male sex

INTRODUCTION

Social deprivation during early life can severely affect mental health later in adulthood, leading to the development of behavioural traits associated with several major psychiatric disorders including schizophrenia. This has led to the application of social isolation in laboratory animals to model the impact of environmental factors on the aetiopathology of schizophrenia. However, controversy exists over the precise behavioural profile and the robustness of some of the reported effects of social isolation rearing.

MATERIALS AND METHODS

Here, we evaluated the efficacy of postweaning social isolation to induce schizophrenia-related behavioural deficits in C57BL/6 mice of both sexes.

RESULTS

The effects of social isolation clearly differed between sexes: isolated male but not female mice exhibited multiple habituation deficits and enhanced locomotor reaction to amphetamine.

DISCUSSION

The preferential vulnerability in the male sex corresponds well with the earlier disease onset and poorer prognosis in male relative to female schizophrenic patients. In contrast, we observed no evidence for a disruption of sensorimotor gating in the prepulse inhibition paradigm despite the efficacy of social isolation to alter startle reactivity. With both success and failure in the induction of schizophrenia-related endophenotypes, the present study thus provides important characterizations and qualifications to the application of the social isolation model in mice.

CONCLUSIONS

We conclude that social isolation in mice represents a valuable tool for the examination of candidate genes within the context of the "two-hit" hypothesis of the aetiological processes in schizophrenia.

The coping experiences of carers who live with someone who has schizophrenia

AIMS AND OBJECTIVES

The purpose of this study was to understand the coping experiences of carers living with a schizophrenic family member. Our research may be a valuable reference for mental health professionals seeking to improve the quality of care for people with schizophrenia and their carers.

DESIGN

We employed a qualitative descriptive phenomenological research methodology to understand the coping experiences of carers living with a schizophrenic family member.

METHODS

Purposive sampling and in-depth, face-to-face interviews were used to collect data. When data saturation was reached, the sample size comprised 10 carers (five men and five women). The interview focused on the carer's coping experience. During the process of data collection and data analyis we established epoches (bracketing) and returned to the reality of the carers' experience to keep the data objective. Narratives were analysed according to Colaizzi's seven steps method.

RESULTS

The two most commonly used coping mechanisms that emerged from this study were psychological coping strategies (cognitive, behavioural and emotional) and social coping strategies (religious, social and professional support). Furthermore, three factors were found in the study, including low social status, traditional help-seeking behaviours and feelings of shame.

CONCLUSION

Findings from this study demonstrate the importance of understanding the coping experiences of carers who have a family member with schizophrenia. Further research is needed to identify more important detailed factors that affect the coping strategies of carers. Relevance to clinical practice. Community mental health care professionals need to improve the quality of care for helping carers living with a family member who has schizophrenia. It is important to develop effective coping intervention strategies that help carers cope with the stress and strain of caring for a family member with schizophrenia.

Incorporating the prevention paradigm into administrative psychiatry

This overview describes the application of primary, secondary, and tertiary prevention-as well as universal, selective, and indicated preventive interventions-to psychiatric and substance use disorders. Ways in which the psychiatrist with a clearly defined administrative role, such as the medical director of a program, service, agency, or organization, or a psychiatrist in some other directorial role (eg, director of education or clinical program director), can apply the prevention paradigm are described. Specifically, a prevention orientation is relevant to administrative psychiatry in the domains of service delivery, education and training, research, and community consultation and advocacy.

Preventing depression after stroke

Mental health prevention research is an emerging and intriguing field. Preventing mental disorders is attractive as successful prevention, as it could potentially avert both emotional suffering and illness related morbidity and mortality. Several studies have looked at preventing post-stroke depression, a common complication of stroke. In this review article, we will first provide a conceptual overview of mental health prevention research. Then, we will discuss recent research supporting the prevention of depression after stroke and the likely positive effect successful prevention may have on non-psychiatric outcomes.

Towards an immuno-precipitated neurodevelopmental animal model of schizophrenia

Epidemiological studies have indicated an association between maternal bacterial and viral infections during pregnancy and the higher incidence of schizophrenia in the resultant offspring post-puberty. One hypothesis asserts that the reported epidemiological link is mediated by prenatal activation of the foetal immune system in response to the elevation of maternal cytokine level due to infection. Here, we report that pregnant mouse dams receiving a single exposure to the cytokine-releasing agent, polyriboinosinic-polyribocytidilic acid (PolyI:C; at 2.5, 5.0, or 10.0 mg/kg) on gestation day 9 produced offspring that subsequently exhibited multiple schizophrenia-related behavioural deficits in adulthood, in comparison to offspring from vehicle injected or non-injected control dams. The efficacy of the PolyI:C challenge to induce cytokine responses in naïve non-pregnant adult female mice and in foetal brain tissue when injected to pregnant mice were further ascertained in separate subjects: (i) a dose-dependent elevation of interleukin-10 was detected in the adult female mice at 1 and 6h post-injection, (ii) 12 h following prenatal PolyI:C challenge, the foetal levels of interleukin-1beta were elevated. The spectrum of abnormalities included impairments in exploratory behaviour, prepulse inhibition, latent inhibition, the US-pre-exposure effect, spatial working memory; and enhancement in the locomotor response to systemic amphetamine (2.5 mg/kg, i.p.) as well as in discrimination reversal learning. The neuropsychological parallels between prenatal PolyI:C treatment in mice and psychosis in humans, demonstrated here, leads us to conclude that prenatal PolyI:C treatment represents one of the most powerful environmental-developmental models of schizophrenia to date. The uniqueness of this model lies in its epidemiological and immunological relevance. It is, sui generis, ideally suited for the investigation of the neuropsychoimmunological mechanisms implicated in the developmental aetiology and disease processes of schizophrenia.