Iron homeostasis alterations and risk for akathisia in patients treated with antipsychotics: A systematic review and meta-analysis of cross-sectional studies

Restless legs syndrome, neuroleptic-induced akathisia, and opioid-withdrawal restlessness: shared neuronal mechanisms?

Restlessness is a core symptom underlying restless legs syndrome (RLS), neuroleptic-induced akathisia, and opioid withdrawal. These three conditions also share other clinical components suggesting some overlap in their pathophysiology. Recent prospective studies demonstrate the frequent incidence of RLS-like symptoms during opioid withdrawal and supervised prescription opioid tapering. Based on the therapeutic role of µ-opioid receptor (MOR) agonists in the three clinical conditions and recent preclinical experimental data in rodents, we provide a coherent and unifying neurobiological basis for the restlessness observed in these three clinical syndromes and propose a heuristic hypothesis of a key role of the specific striatal neurons that express MORs in akathisia/restlessness.

Outcomes of electroconvulsive therapy in patients with depressive symptoms with versus without comorbid personality disorders/traits: A systematic review and meta-analysis

AIMS

To assess electroconvulsive therapy (ECT) outcomes in patients affected by depressive symptoms with versus without additional comorbid personality disorders/traits.

METHODS

We identified observational studies investigating ECT clinical outcomes in patients affected by depressive symptoms with versus without comorbid personality disorders/traits in Embase/Medline in 11/2022. Our protocol was registered with PROSPERO (CRD42023390833). Study quality was evaluated using the Newcastle-Ottawa-Scale. Our primary outcomes were ECT response and remission rates. Meta-regression analyses included effects of in/outpatient percentages, age, number of ECT sessions, and electrode placement; subgroup analyses included the assessment methods for personality disorders/traits. We performed sensitivity analyses after excluding poor-quality studies.

RESULTS

A total of 20 studies (n = 11,390) were included in our analysis. Patients with comorbid personality disorders/traits had lower remission rates (OR = 0.42, 95% CI = 0.31, 0.58, p < 0.001) with substantial heterogeneity (I2  = 93.0%) as well as lower response rates (OR = 0.35, 95% CI = 0.24, 0.51, n = 5129, p < 0.001) with substantial heterogeneity (I2  = 93.0%) compared with patients without comorbid personality disorders/traits. Relapse rates were higher in patients with versus without comorbid personality disorders/traits (OR = 3.23, 95% CI = 1.40, 7.45, k = 4, n = 239, p = 0.006) with moderate heterogeneity (I2  = 75.0%) and post-ECT memory impairment was more frequent in patients with versus without comorbid personality disorders/traits (OR = 1.41, 95% CI = 1.36, 1.46, k = 4, n = 471, p < 0.001) with minimal heterogeneity (I2  = 0.0%). Dropout rates were higher in patients with versus without comorbid personality disorders/traits (OR = 1.58, 95% CI = 1.13, 2.21, k = 3, n = 6145, p = 0.008).

CONCLUSIONS

Patients with comorbid personality disorders/traits treated with ECT are reported to have lower response and remission rates and higher rates of side effects and relapse rates compared with patients without personality disorders/traits.

Iron Deficiency in Attention-Deficit Hyperactivity Disorder, Autism Spectrum Disorder, Internalizing and Externalizing Disorders, and Movement Disorders

This article reviews the role of iron in brain development and function, with a focus on the association between iron deficiency (ID) and neuropsychiatric conditions. First, we describe how ID is defined and diagnosed. Second, the role of iron in brain development and function is summarized. Third, we review current findings implicating ID in a number of neuropsychiatric conditions in children and adolescents, including attention deficit hyperactivity disorder and other disruptive behavior disorders, depressive and anxiety disorders, autism spectrum disorder, movement disorders, and other situations relevant to mental health providers. Last, we discuss the impact of psychotropic medication on iron homeostasis.

Restless Legs Syndrome and the Use of Antipsychotic Medication: An Updated Literature Review

Restless legs syndrome or Willis-Ekbom disease (RLS/WED) is a sleep-related movement disorder characterized by an urge to move the legs. This impulse is usually accompanied by an uncomfortable and unpleasant sensation in the legs, which worsens at night and during periods of inactivity and is relieved by movement. Several studies in the literature reported the association between RLS and different antipsychotic medications. with Olanzapine, Quetiapine, and Clozapine identified as the most common causes. The literature suggests that the development of RLS in antipsychotic users may be attributed to the inhibition of dopaminergic neurotransmission or the impact of antipsychotics on iron metabolism. Diagnosing antipsychotic-induced RLS remains a substantial challenge in clinical practice, with challenges in the management of this condition also being widely reported in the current literature. In this article, we will review the evidence suggesting the association between RLS and the use of antipsychotic medications, differentiate between RLS and other movement disorders, and give a brief review of the pathophysiology, diagnosis, and management of RLS and its challenges among psychotic patients.

Mechanisms Underlying Antipsychotic-Induced NAFLD and Iron Dysregulation: A Multi-Omic Approach

Atypical antipsychotic (AA) medications are widely prescribed for the treatment of psychiatric disorders, including schizophrenia, bipolar disorder and treatment-resistant depression. AA are associated with myriad metabolic and endocrine side effects, including systemic inflammation, weight gain, dyslipidemia and insulin resistance, all of which are associated with increased incidence of non-alcoholic fatty liver disease (NAFLD). NAFLD is highly prevalent in patients with mental illness, and AA have been shown to increase incidence of NAFLD pre-clinically and clinically. However, the underlying mechanisms have not been described. We mined multi-omic datasets from preclinical murine models of sub-chronic risperidone or olanzapine treatment, in vitro exposure of human cells to risperidone and psychiatric patients following onset of aripiprazole therapy focused on pathways associated with the pathophysiology of NAFLD, including iron accumulation, systemic inflammation and dyslipidemia. We identified numerous differentially expressed traits affecting these pathways conserved across study systems and AA medications. We used these findings to propose mechanisms for AA-associated development of NAFLD and dysregulated iron homeostasis.

Prevalence of impaired kidney function in patients with long-term lithium treatment: A systematic review and meta-analysis

OBJECTIVES

Although lithium renal effects have been extensively investigated, prevalence rates of chronic kidney disease (CKD) in lithium-treated patients vary. Our aim was to provide prevalence estimates and related moderators.

METHODS

We performed a systematic review in PubMed/Embase until November 01, 2021, conducting a random effects meta-analysis of studies evaluating CKD prevalence rates in lithium-treated patients calculating overall prevalence ±95% confidence intervals (CIs). Meta-regression analyses included sex, age, body mass index, smoking, hypertension, diabetes, cardiovascular disease, lithium-treatment dose, duration, and blood levels. Subgroup analyses included sample size, diagnoses, and study design. Pooled odds ratios (OR) were estimated for studies including patients receiving nonlithium treatment. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Five, nine, and six trials were rated as high, fair, and low quality, respectively. In 20 studies (n = 25,907 patients), we estimated an overall prevalence of 25.5% (95% CI = 19.8-32.2) of impaired kidney function; despite lack of differences (p = 0.18), prevalence rates were higher in elderly samples than mixed samples of elderly and nonelderly (35.6%, 95% CI = 21.4-52.9, k = 2, n = 3,161 vs. 25.1%, 95% CI = 19.1-31.3, k = 18, n = 22,746). Prevalence rates were associated with longer lithium treatment duration (p = 0.04). Cross-sectional studies provided lower rates than retrospective studies (14.5%, 95% CI = 13.5-15.5, k = 6, n = 4,758 vs. 29.5%, 95% CI = 22.1-38.0, k = 12, n = 17,988, p < 0.001). Compared with 722,529 patients receiving nonlithium treatment, the OR of impaired kidney function in 14,187 lithium-treated patients was 2.09 (95% CI = 1.24-3.51, k = 8, p = 0.005).

CONCLUSIONS

One-fourth of patients receiving long-term lithium may develop impaired kidney function, although research suffers from substantial heterogeneity between studies. This risk may be twofold higher compared with nonlithium treatment and may increase for a longer lithium treatment duration.

Polycystic ovary syndrome and postpartum depression: A systematic review and meta-analysis of observational studies

OBJECTIVE

To estimate the risk of postpartum depression (PPD) in women with polycystic ovary syndrome (PCOS) and assess related moderators.

METHODS

Observational studies reporting on PPD rates in women with vs. without PCOS were identified in Embase/Medline/PsychInfo/Cinhail in 03/2021 since data inception. Quality of studies was evaluated using the Newcastle-Ottawa-Scale. The primary outcome was the odds ratio (OR, 95% confidence intervals [95%CI]) of PPD in women with vs. without PCOS. Meta-regression analyses included the effects of age, body mass index, percent smokers, history of depression, preterm delivery, hypertension during pregnancy, gestational diabetes and cesarian section as well as subgroup analyses based on the assessment methods for PCOS and PPD. Sensitivity analyses after excluding poor quality studies and cross-sectional studies and sequentially excluding each study were performed.

RESULTS

One study was rated as good, two as fair and three as low-quality. In six studies (n = 934,922), 44,167 women with PCOS were at increased PPD risk compared to 890,755 women without PCOS (OR= 1.45, 95%CI= 1.18 to 1.79, p< 0.001). When excluding one study that underestimated PCOS prevalence, we estimated an OR of 1.59 (95%CI= 1.56 to 1.62, p< 0.001) with reduced heterogeneity (I²= 45.3%). Higher ORs of PPD in women with PCOS were moderated by lower percentage of preterm delivery (co-efficient -0.07, 95%CI= -0.1 to -0.04, p< 0.001). After excluding low-quality studies yielded an OR of 1.58 (95%CI= 1.56 to 1.59, p< 0.001) with heterogeneity dropping (I²= 14.0%).

LIMITATIONS

The methodological heterogeneity of available studies.

CONCLUSIONS

Women with PCOS are at elevated PPD risk with risk moderators requiring further research.

Serum hepcidin / ferroportin levels in bipolar disorder and schizophrenia

BACKGROUND

Despite several alternatives for cellular iron influx, the only mechanism for cellular iron efflux is ferroportin mediated active transport. In cases of ferroportin dysfunction, iron accumulates in the cell and causes ferroptosis. Hepcidin suppresses ferroportin levels and inflammatory activation increases hepcidin production. Mild inflammation in schizophrenia and bipolar disorder may alter hepcidin and ferroportin.

METHODS

The study included a total of 137 patients aged 18-65 years, 57 diagnosed with schizophrenia and 80 with bipolar disorder, according to the DSM-IV diagnostic criteria, and a control group (HC) of 42 healthy individuals. Biochemical analyses, thyroid function tests, hemogram, serum iron level, iron-binding capacity, and ferritin levels were examined. Serum levels of hepcidin and ferroportin were measured with enzyme-linked immunosorbent assay (ELISA) method.

RESULTS

A statistically significant difference was determined between the groups in terms of the serum ferroportin levels (F = 15.69, p < 0.001). Post-hoc analyses showed that the schizophrenia group had higher ferroportin levels than in the bipolar group (p < 0.001) and HCs (p < 0.001). Hepcidin levels did not differ between the groups. Chlorpromazine equivalent doses of antipsychotics correlated with ferroportin levels (p = 0.024).

CONCLUSION

Ferroportin levels were increased in the schizophrenia group, although iron and hepcidin levels were within normal ranges. Antipsychotics may alter the mechanisms which control ferroportin levels. Further studies are needed to examine the relationships between antipsychotics and iron metabolism for determination of causal relationship.

Matrix Metalloproteinase 9 Blood Alterations in Patients With Schizophrenia Spectrum Disorders: A Systematic Review and Meta-Analysis

BACKGROUND

Matrix metalloproteinase 9 (MMP-9), an extracellular network protease implicated in glutamatergic signaling, may be part of the pathophysiology of schizophrenia spectrum disorders (SSD).

METHODS

We performed a systematic review in PubMed/Embase until July 15, 2020, conducting a random-effects meta-analysis of studies comparing MMP-9 blood levels in SSD vs healthy controls (HCs) and psychiatric controls (PCs), calculating between-group differences in standardized mean differences (SMDs) ± 95% confidence intervals (CIs). Meta-regression analyses included sex, age, illness duration, antipsychotic dose, and Positive and Negative Syndrome Scale (PANSS) total/subscales. Subgroup analyses included first-episode patients (FEP) vs non-FEP, each vs HCs and vs PCs, and blood sample type. Study quality was assessed using the Newcastle-Ottawa scale.

RESULTS

Four, five, and two trials were rated as high, fair, and low quality. In 11 studies (n = 1443), 643 patients (age = 36.7 ± 14.1 years, females = 42.9%) were compared with HCs (n = 631), with 4 studies including also 169 PCs. MMP-9 levels were higher in SSD vs HCs (SMD = 0.52, 95%CI = 0.20-0.85, P = .002), but not in PCs vs HCs (n = 132, after removing one implausible outlier [SMD = 0.33, 95%CI = -0.16 to 0.85, P = .082]). MMP-9 differences between SSD and HCs were associated with higher PANSS total (coefficient = 0.02, 95%CI = 0.01-0.02, P < .001), PANSS positive (coefficient = 0.08, 95%CI = 0.02-0.13, P = .006), and PANSS general scores (coefficient = 0.02, 95%CI = 0.01-0.03, P < .001). MMP-9 level differences vs HCs did not vary significantly between FEP (n = 103, SMD = 0.44, 95%CI = 0.15-0.72, P = .71) and non-FEP patients (n = 466, SMD = 0.59, 95%CI = 0.38-0.80; P = .34) (FEP vs non-FEP: P = .39). In four high-quality studies, MMP-9 levels remained significantly higher in SSD vs HCs (SMD = 0.82, 95%CI = 0.03-1.61).

CONCLUSIONS

Findings suggest MMP-9 upregulation in SSD, requiring further validation and understanding of related pathways.