Nutritional psychiatry in the treatment of psychotic disorders: Current hypotheses and research challenges

Nutrition Education in Psychiatry Residency Programs: A Call to Action

The burden of disease attributable to mental health is expected to rise in the coming decades. Poor nutritional status is considered a modifiable risk factor for general mental health. In fact, nutrition interventions are now accepted as a core strategy in mental healthcare to combat physical health inequalities and life-expectancy gap in people with certain psychiatric disorders. However, most psychiatrists are not familiar with evidence for the potential therapeutic benefits of diet in psychiatric illness, and this may be related to sparse nutrition education for physicians. Thus, there is a need to integrate nutritional management in psychiatric practice, but there is a gap in medical education that would support this practice. Here, we discuss evidence for and challenges in 1) assessing diet quality in psychiatric illness, 2) recommending improvements in diet quality and specific dietary patterns in psychiatric illness, and 3) recommending dietary supplements in psychiatric illness. This discussion serves as a call to develop nutrition curricula within psychiatry residency programs.

Nutrition and schizophrenia: associations worthy of continued revaluation

BACKGROUND

Accumulating evidence have shown that diet and nutrition play significant roles in mental illness, such as depression, anxiety and bipolar disorder. However, comprehensive evaluation of the relationship between nutrition and schizophrenia is lacking.

OBJECTIVE

The present review aims to synthetic elaborate the associations between nutrition and schizophrenia. Relevant studies on dietary patterns, macronutrients, micronutrients were performed through a literature search to synthesize the extracted data.

SUMMARY

Dietary interventions may help prevent the occurrence of schizophrenia, or delay symptoms: Healthy diets like nutritious plant-based foods and high-quality protein, have been linked to reducing the risk or symptoms of schizophrenia. Moreover, diet high in saturated fat and sugar is linked to more serious outcomes of schizophrenia. Additionally, when N-acetylcysteine acts as an adjuvant therapy, the overall symptoms of schizophrenia are significantly reduced. Also nascent evidence showed mental disorders may be related to intestinal microbiota dysfunction. Our study offered important insights into the dietary habits of patients with schizophrenia and the potential impact of nutritional factors on the disease. We also emphasized the need for further research, particularly in the form of large randomized double-blind controlled trials, to better understand the effects of nutrients on schizophrenia symptoms in different populations and disease types.

Homicide or Happiness: Did Folate Fortification and Public Health Campaigns Influence Homicide Rates and the Great American Crime Decline?

The last several years have witnessed a remarkable growth in research directed at nutrition and behavior, with increased interest in the field of nutritional criminology. It is becoming clear that dietary patterns and specific nutrients play an important role in cognition and behavior, including those related to aggression, violence, and antisocial activity. Included in this expanding knowledge base is the recognition that folate, through multiple pathways, including enzymatic reactions and gut microbiome ecology, plays a critical role in central nervous system functioning. These mechanistic advances allow for a retrospective analysis of a topic that remains unexplained-the sudden and unpredicted drop in homicide and other violent crime rates in the United States and other nations in the 1990s. Here, we revisit this marked reduction in homicide rates through the lens of the coincident public health campaign (and subsequent mandatory fortification) to increase folic acid intake. Based on objectively measured blood folate levels through the National Health and Nutrition Examination Surveys, there is little doubt that tissue folate witnessed a dramatic rise at the national level from 1988 through 2000. Drawing from accumulated and emerging research on the neurobehavioral aspects of folate, it is our contention that this relatively sudden and massive increase in tissue folate levels may have contributed to reductions in violent crime in the United States.

Human gut microbiome, diet, and mental disorders

Diet is one of the most important external factor shaping the composition and metabolic activities of the gut microbiome. The gut microbiome plays a crucial role in host health, including immune system development, nutrients metabolism, and the synthesis of bioactive molecules. In addition, the gut microbiome has been described as critical for the development of several mental disorders. Nutritional psychiatry is an emerging field of research that may provide a link between diet, microbial function, and brain health. In this study, we have reviewed the influence of different diet types, such as Western, Mediterranean, vegetarian, and ketogenic, on the gut microbiota composition and function, and their implication in various neuropsychiatric and psychological disorders.

Development and Validation of a Food Frequency Questionnaire for Evaluating the Nutritional Status of Patients with Serious Mental Illnesses (DIETQ-SMI) in Bahrain

General food frequency questionnaires (FFQs) have not been tailored for or validated in individuals with psychiatric disorders. Given the unique eating behaviors of patients with serious mental illnesses (SMIs), custom-made tools are needed. Therefore, we developed and validated an FFQ customized to individuals with SMIs. A total of 150 adults with SMIs (schizophrenia, bipolar disorder, or major depression) were recruited from Bahrain. The participants completed the 50-item Dietary Intake Evaluation Questionnaire for Serious Mental Illness (DIETQ-SMI) FFQ and a 3-day food record (FR). The validity of the FFQ was assessed by comparing nutrient intake to FR intake using correlation and reliability statistics. The DIETQ-SMI demonstrated a good ranking validity compared to the FR based on correlation coefficients (rho 0.33 to 0.92) for energy and macro- and micronutrients. The FFQ had high internal consistency (McDonald's omega = 0.84; Cronbach's alpha = 0.91) and test-retest reliability (ICC > 0.90). The FFQ tended to estimate higher absolute intakes than the FR but adequately ranked the intakes. The FFQ value was correlated with the FR for all the items (p < 0.001). The DIETQ-SMI is a valid and reliable FFQ for ranking dietary intake in individuals with an SMI. It can help assess nutritional status and, subsequently, guide interventions in high-risk psychiatric populations.

Are probiotics effective in reducing the metabolic side effects of psychiatric medication? A scoping review of evidence from clinical studies

The psychopharmacological treatment of patients with schizophrenia or depression is often accompanied by serious side effects. In particular, the clinical findings of weight gain are worrying, as this side effect can lead to various medical sequelae in the future. However, the treatment of metabolic changes in psychiatric patients is often neglected or unsuccessful. An improved knowledge of possible therapeutic approaches is needed. The aim of this study was to provide an overview of the utilisation and effectiveness of probiotics in reducing weight gain in patients with severe mental illness. A scoping review of studies published until 15 June 2022 was conducted to identify studies using probiotics in people with schizophrenia or depression. We systematically searched the databases EMBASE, PubMed (MEDLINE), Web of Science and SCOPUS with a predefined search string. In addition, reference lists of relevant publications were examined for additional studies. The studies were assessed by two reviewers. The primary outcomes were weight-related measurements. The secondary outcomes were metabolic blood parameters and gut microbiota. Four studies ultimately met the inclusion criteria. Two studies in which probiotics were administered did not find significant effects on pharmacologically induced weight gain. The other two studies examined the effects of synbiotics (a combination of probiotics and prebiotics). Interestingly, less weight gain was observed in individuals with this combined intervention. Adjustments in diet can be helpful and are generally well-accepted interventions in the fight against pharmacologically induced weight gain. The clinical use of probiotics and prebiotics (or synbiotics) as dietary interventions may represent a promising additional strategy in this regard. However, the few studies available showed no clear conclusions.

Practice recommendations and referrals, perceptions of efficacy and risk, and self-rated knowledge regarding complementary medicine: a survey of Australian psychologists

BACKGROUND

Many people with mental health problems use a range of complementary medicine (CM), including over the counter products, practices, and utilise the services of CM practitioners. Psychologists are likely to consult with clients using CM, in some form, as part of their broader mental health care. The aim of this research was to determine the number of types of CM products, practices, and practitioners are recommended and/or referred by Australian psychologists as part of their clinical practice, as well as explore the relationship between psychologists' perspectives on the risk and relevance of engaging with CM in psychology.

METHODS

Survey data was collected from psychologists in clinical practice who self-selected to participate in the study via an online 79-item questionnaire exploring core aspects of CM engagement in psychology clinical practice.

RESULTS

Amongst the 201 psychologists, 5% reported not recommending any type of CM, with 63% recommending four or more types of CM. Further, 25% had not referred to a CM practitioner, while 33% had referred to four or more types of CM practitioner. Psychologists are recommending and referring to CM even when they perceive their knowledge of CM to be poor, and that engaging with CM was a risk.

CONCLUSION

This study provides insights into psychologist perceptions of CM within psychology practice and how these perceptions are associated with rates of recommending and referring to CM as part of their clinical practice. These findings may inform the development of CM relevant education and guidelines for psychologists.

The engagement of psychology with complementary medicine: A critical integrative review

Amidst the global rise in complementary medicine (CM) use for mental health, a substantial number of clients consulting a psychologist also utilise at least one form of CM. Yet, how psychologists should engage with CM in their clinical practice (e.g., how to respond to a client disclosing CM use or enquiries regarding CM products or services for mental health) remains contested and unclear. In response, a systematic integrative review was conducted to examine empirical literature reporting on one or more aspects of the relationship between psychology (incorporating clinical practice, professional associations and academia) and CM, and how that relationship may relate to or inform psychologists' engagement with CM in their clinical practice. Twenty-seven peer-reviewed articles met the specific inclusion criteria and quality appraisal was employed. Analysis shows a substantial number of psychologists are engaging with, or are interested in engaging with, CM in their clinical practice. Analysis identified a dissonance between psychologists' engagement with CM in clinical practice and the limited engagement of the broader discipline of psychology with CM. Further research is required to understand these differing types of engagement with a view to helping inform relevant policy and practice guidelines, and ultimately assist psychologists in navigating CM in their clinical practice.

Adverse effects of antipsychotics on sleep in patients with schizophrenia. Systematic review and meta-analysis

Introduction

Our objective was to conduct a systematic review and meta-analysis of adverse effects on sleep in patients with schizophrenia receiving antipsychotic treatment.

Methods

A systematic search was performed in PubMed, Cochrane Central, Embase, Toxline, Ebsco, Virtual Health Library, Web of Science, SpringerLink, and in Database of abstracts of Reviews of Effects of Randomized Clinical Trials to identify eligible studies published from January 1990 to October 2021. The methodological quality of the studies was evaluated using the CONSORT list, and the Cochrane bias tool. Network meta-analysis was performed using the Bayesian random-effects model, with multivariate meta-regression to assess the association of interest.

Results

87 randomized clinical trials were identified that met the inclusion criteria, and 70 articles were included in the network meta-analysis. Regarding the methodological quality of the studies, 47 had a low or moderate bias risk. The most common adverse effects on sleep reported in the studies were insomnia, somnolence, and sedation. The results of the network meta-analysis showed that ziprasidone was associated with an increased risk of insomnia (OR, 1.56; 95% credible interval CrI, 1.18-2.06). Several of the included antipsychotics were associated with a significantly increased risk of somnolence; haloperidol (OR, 1.90; 95% CrI, 1.12-3.22), lurasidone (OR, 2.25; 95% CrI, 1.28-3.97) and ziprasidone (OR, 1.79; 95% CrI, 1.06-3.02) had the narrowest confidence intervals. In addition, perphenazine (OR, 5.33; 95% CrI, 1.92-14.83), haloperidol (OR, 2.61; 95% CrI, 1.14-5.99), and risperidone (OR, 2.41; 95% CrI, 1.21-4.80) were associated with an increased risk of sedation compared with placebo, and other antipsychotics did not differ. According to the SUCRAs for insomnia, chlorpromazine was ranked as the lowest risk of insomnia (57%), followed by clozapine (20%), while flupentixol (26 %) and perospirone (22.5%) were associated with a lower risk of somnolence. On the other hand, amisulpride (89.9%) was the safest option to reduce the risk of sedation.

Discussion

Insomnia, sedation, and somnolence were the most frequent adverse effects on sleep among the different antipsychotics administered. The evidence shows that chlorpromazine, clozapine, flupentixol, perospirone, and amisulpride had favorable safety profiles. In contrast, ziprasidone, perphenazine, haloperidol, and risperidone were the least safe for sleep.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42017078052, identifier: PROSPERO 2017 CRD42017078052.

Independent and Combined Effects of Probiotics and Prebiotics as Supplements or Food-Rich Diets on a Propionic-Acid-Induced Rodent Model of Autism Spectrum Disorder

The link between nutrition and autism spectrum disorder (ASD) as a neurodevelopmental condition, which is clinically presented as significant delays or deviations in interaction and communication, has provided a fresh point of view and signals that nutrition may play a role in the etiology of ASD, as well as playing an effective role in treatment by improving symptoms. In this study, 36 male albino rat pups were used. They were randomly divided into five groups. The control group was fed only a standard diet and water for the 30 days of the experiment. The second group, which served as a propionic acid (PPA)-induced rodent model of ASD, received orally administered PPA (250 mg/kg body weight (BW)) for 3 days, followed by feeding with a standard diet until the end of the experiment. The three other groups were given PPA (250 mg/kg body weight (BW)) for 3 days and then fed a standard diet and orally administered yogurt (3 mL/kg BW/day), artichokes (400 mL/kg BW/day), and a combination of Lacticaseibacillus rhamnosus GG at 0.2 mL daily (1 × 10⁹ CFU; as the probiotic of yogurt) and luteolin (50 mg/kg BW/day; as the major antioxidant and anti-inflammatory ingredient of artichokes) for 27 days. Biochemical markers, including gamma-aminobutyric acid (GABA), reduced glutathione (GSH), glutathione peroxidase (GPx1), tumor necrosis factor-alpha (TNF-α), interleukin-6 (IL-6), and interleukin-10 (IL-10), were measured in brain homogenates in all groups. The data showed that while PPA demonstrated oxidative stress and neuroinflammation in the treated rats, yogurt, Lacticaseibacillus rhamnosus GG as a probiotic, and luteolin as a prebiotic ingredient in artichokes were effective in alleviating the biochemical features of ASD. In conclusion, nutritional supplementation seems to be a promising intervention strategy for ASD. A combined dietary approach using pro- and prebiotics resulted in significant amelioration of most of the measured variables, suggesting that multiple interventions might be more relevant for the improvement of biochemical autistic features, as well as psychological traits. Prospective controlled trials are needed before recommendations can be made regarding the ideal ASD diet.

Halting the Metabolic Complications of Antipsychotic Medication in Patients with a First Episode of Psychosis: How Far Can We Go with the Mediterranean Diet? A Pilot Study

Patients with first-episode psychosis (FEP) often adopt unhealthy dietary patterns, with a risk of weight gain and metabolic and cardiovascular disease. In 21 FEP patients receiving nutritional intervention based on the Mediterranean diet (MedDiet), we explored differences in anthropometric and biometric parameters, according to their antipsychotic (AP) medication: AP1, associated with a lower risk, or AP2, associated with a higher risk of weight gain and metabolic complications. The blood biochemical profile was recorded before and after dietary intervention, and dietary habits and body composition were monitored for six months. Following intervention, all of the patients recorded significant increases in the consumption of fruit and vegetables and decreases in red meat and poultry consumption, with closer adherence to the MedDiet and a reduction in the daily intake of calories, carbohydrates, and sodium. Vegetable consumption and energy, protein, and carbohydrate intake were lower in AP1 patients than in AP2 patients. There was no significant weight gain overall. A reduction was demonstrated in total and LDL cholesterol, sodium, urea, and iron (lower in AP1 patients). It was evident that AP medication affected blood levels of lipids, urea, and iron of FEP patients, but MedDiet nutritional intervention led to a significant improvement in their eating habits, with a restriction in weight gain and a decrease in blood sodium and urea.

Three-year outcomes and predictors for full recovery in patients with early-stage psychosis

In the present study, various outcomes over 3-year period in patients with early stage psychosis including remission, recovery, relapse and medication adherence were investigated. Predictor for full recovery at year 3 was also examined. Three-year follow-up data in 534 patients with schizophrenia spectrum disorders (SSD) and psychotic disorder not otherwise specified (PNOS) were examined for overall outcome trajectories. The data of completers at year 3 (n = 157) were used to identify predictors for recovery using logistic regression. The rates of symptomatic remission and full recovery at 6-, 12-, 24-, and 36-month follow-up were 76.10, 69.20, 79.50, and 79.10%, and 22.80, 26.40, 28.60, and 39.60%, respectively. The rates of drop-out and relapse at 6-, 12-, 24-, and 36-month follow-up were 25.4, 29.5, 38.6, and 51.1%, and 3.7, 8.9, 19.0, and 38.9%, respectively. The rates of good adherence and prescription of Long-Acting Injectable Antipsychotics (LAIA) at 6-, 12-, 24- and 36-month follow-up were 87.8, 88.0, 91.9, and 93.9%, and 18.3, 21.7, 22.0, and 25.5%, respectively. Significant predictors for full recovery were duration of untreated psychosis (DUP), family intimacy and physical activity. We observed similar or better results on remission, recovery, and relapse rates compared to other previous studies. Effective psychosocial intervention should be provided to shorten the gap between remission and recovery rates and to address DUP, family issues, and exercise to enhance recovery.

Cytokine Imbalance as a Biomarker of Treatment-Resistant Schizophrenia

Treatment-resistant schizophrenia (TRS) is an important and unresolved problem in biological and clinical psychiatry. Approximately 30% of cases of schizophrenia (Sch) are TRS, which may be due to the fact that some patients with TRS may suffer from pathogenetically “non-dopamine” Sch, in the development of which neuroinflammation is supposed to play an important role. The purpose of this narrative review is an attempt to summarize the data characterizing the patterns of production of pro-inflammatory and anti-inflammatory cytokines during the development of therapeutic resistance to APs and their pathogenetic and prognostic significance of cytokine imbalance as TRS biomarkers. This narrative review demonstrates that the problem of evaluating the contribution of pro-inflammatory and anti-inflammatory cytokines to maintaining or changing the cytokine balance can become a new key in unlocking the mystery of “non-dopamine” Sch and developing new therapeutic strategies for the treatment of TRS and psychosis in the setting of acute and chronic neuroinflammation. In addition, the inconsistency of the results of previous studies on the role of pro-inflammatory and anti-inflammatory cytokines indicates that the TRS biomarker, most likely, is not the serum level of one or more cytokines, but the cytokine balance. We have confirmed the hypothesis that cytokine imbalance is one of the most important TRS biomarkers. This hypothesis is partially supported by the variable response to immunomodulators in patients with TRS, which were prescribed without taking into account the cytokine balance of the relation between serum levels of the most important pro-inflammatory and anti-inflammatory cytokines for TRS.

Role of diet and its effects on the gut microbiome in the pathophysiology of mental disorders

There is emerging evidence that diet has a major modulatory influence on brain-gut-microbiome (BGM) interactions with important implications for brain health, and for several brain disorders. The BGM system is made up of neuroendocrine, neural, and immune communication channels which establish a network of bidirectional interactions between the brain, the gut and its microbiome. Diet not only plays a crucial role in shaping the gut microbiome, but it can modulate structure and function of the brain through these communication channels. In this review, we summarize the evidence available from preclinical and clinical studies on the influence of dietary habits and interventions on a selected group of psychiatric and neurologic disorders including depression, cognitive decline, Parkinson's disease, autism spectrum disorder and epilepsy. We will particularly address the role of diet-induced microbiome changes which have been implicated in these effects, and some of which are shared between different brain disorders. While the majority of these findings have been demonstrated in preclinical and in cross-sectional, epidemiological studies, to date there is insufficient evidence from mechanistic human studies to make conclusions about causality between a specific diet and microbially mediated brain function. Many of the dietary benefits on microbiome and brain health have been attributed to anti-inflammatory effects mediated by the microbial metabolites of dietary fiber and polyphenols. The new attention given to dietary factors in brain disorders has the potential to improve treatment outcomes with currently available pharmacological and non-pharmacological therapies.

Design and pilot evaluation of an evidence-based worksheet and clinician guide to facilitate nutrition counselling for patients with severe mental illness

BACKGROUND

Schizophrenia spectrum disorders (SSD) are severe, persistent mental illnesses resulting in considerable disability and premature mortality. Emerging evidence suggests that diet may be a modifiable risk factor in mental illness; however, use of nutritional counselling as a component of psychiatric clinical practice is limited. The objective of this project is the design and evaluate a worksheet and clinician guide for use in facilitating nutritional counseling in the context of existing mental health care.

METHODS

The worksheet and clinician guide were developed based on the results of a recent scoping review on the relationship between diet and mental health symptoms among individuals with SSD. A feedback process involved a focus group with psychiatrists and interviews with individuals with lived experience with psychosis. Participants were asked a series of structured and open-ended questions. Interviews were transcribed and data units were allocated to categories from an existing framework. The comments were used to guide modifications to the worksheet and clinician guide. A brief interview with all participants was completed to gather feedback on the final version.

RESULTS

Five psychiatrist participants and six participants with lived experience completed interviews. Participants provided positive comments related to the worksheet design, complexity and inclusion of interactive components. A novel theme emerged relating to the lack of nutritional counselling in psychiatric training and clinical practice. Many constructive comments were provided which resulted in meaningful revisions and improvements to the worksheet and clinician guide design and content. All participants were satisfied with the final versions.

CONCLUSIONS

A worksheet and clinician guide designed to facilitate nutritional counselling with individuals with SSD was found to be acceptable to all participants following a process of feedback and revision. Further research and dissemination efforts aimed at increasing the use of nutritional counselling in psychiatric practice are warranted.

The Development of a Nutrition Screening Tool for Mental Health Settings Prone to Obesity and Cardiometabolic Complications: Study Protocol for the NutriMental Screener

People living with serious mental illness (SMI) experience physical health complications at disproportionate rates to people without an SMI. Unhealthy dietary intake and disordered eating behaviors are key driving factors. There is a lack of valid nutrition-risk screening tools targeted to mental health services, and typically used nutrition-risk screening tools are not suitable for mental health services. This paper details the rationale and study protocol for development and validation of the NutriMental screener, a tool for use in clinical practice to identify service users who are at risk for common nutrition issues experienced by this population group and trigger referral to a specialist clinician. The development process includes five phases. Phase I is the development of nutrition-related domains of interest from screening tools used in mental health services. Phase II involves a literature review and service-user interviews to identify additional domains. Phase III consists of international workshops with relevant clinicians and persons with SMI to gain a consensus on questions to be included in the draft tool. Phase IV involves conducting multinational feasibility and preliminary validation studies. Phase V consists of performing formal validation studies. The development of a nutrition-risk screening tool for mental health services is a necessary step to help rectify the physical-health disparities and life-expectancy gap for people with SMI.

Nutrition, nutritional deficiencies, and schizophrenia: An association worthy of constant reassessment

Schizophrenia is a mental health disorder that occurs worldwide, cutting across cultures, socioeconomic groups, and geographical barriers. Understanding the details of the neurochemical basis of schizophrenia, factors that contribute to it and possible measures for intervention are areas of ongoing research. However, what has become more evident is the fact that in targeting the neurochemical imbalances that may underlie schizophrenia, the type of response seen with currently available phamacotherapeutic agents does not provide all the answers that are needed. Therefore, the possible contribution of non-pharmacological approaches to schizophrenia management is worthy of consideration. In recent times, research is beginning to show nutrition may play a possibly significant role in schizophrenia, affecting its development, progression and management; however, while attempts had been made to examine this possible relationship from different angles, articles addressing it from a holistic point of view are not common. In this review, we examine existing scientific literature dealing with the possible relationship between nutrition and schizophrenia, with a view to elucidating the impact of diet, nutritional deficiencies and excesses on the aetiology, progression, management and outcome of schizophrenia. Secondly, the effect of nutritional supplements in prevention, as sole therapy, or adjuncts in schizophrenia management are examined.

Psychische Komorbiditäten bei Jugendlichen und jungen Erwachsenen mit Typ-1-Diabetes

Jugendliche und junge Erwachsene mit Typ-1-Diabetes sind häufig von komorbiden psychischen Störungen betroffen. Dabei zeigt die Studienlage zur Verbreitung ein heterogenes und inkonsistentes Bild. Diagnose und Behandlung der somatopsychischen Begleiterkrankungen beeinflussen den Behandlungs- und Krankheitsverlauf sowie die Lebensqualität der Betroffenen. Trotzdem wird dies in der klinischen Praxis selten frühzeitig berücksichtigt. Das multizentrische Verbundprojekt COACH verfolgt das Ziel, die Erkennung und Behandlung psychischer Komorbidität für diese Zielgruppe in der bundesweiten Routineversorgung zu optimieren.

The gut microbiome and antipsychotic treatment response

Patients with psychosis usually respond to one antipsychotic drug and not to another; one third fail to respond to any. Some patients, who initially do well, stop responding. Some develop serious side effects even at low doses. While several of the reasons for this variability are known, many are not. The aim of this review is to explore the potential role of intestinal organisms in response/non-response to antipsychotics. Much of the literature in this field is relatively new and still, for the most part, theoretical. A growing number of animal experiments and clinical trials are starting to point, however, to substantial effects of antipsychotics on the composition of gut bacteria and, reciprocally, to the effects of microbiota on the pharmacokinetics of antipsychotic medication. Because so many factors influence the constituents of the human intestine, it is difficult, at present, to sort out how much one or more either enhance or dampen the benefits of antipsychotics or the character/severity of the adverse effects they induce. Dietary and other therapies are being devised to reverse dysbiosis. If successful, such therapies plus the modification of factors that, together, are known to determine the composition of microbiota could help to maximize the effectiveness of currently available antipsychotic therapy.