Can the Positive and Negative Syndrome scale (PANSS) differentiate treatment-resistant from non-treatment-resistant schizophrenia? A factor analytic investigation based on data from the Pattern cohort study

Randomized, double-blind, sham-controlled trial to evaluate the efficacy and tolerability of electroconvulsive therapy in patients with clozapine-resistant schizophrenia

There is no established treatment for patients with clozapine-resistant schizophrenia (CRS). Clozapine augmentation strategies with antipsychotics or others substances are effective in comparison with placebo while and Electroconvulsive therapy (ECT) showed to be effective in comparison with treatment as usual (TAU) but not with placebo (sham-ECT). In the present double- blind randomized controlled trial, we compared 40 outpatients who received 20 sessions of ECT (n = 21) or sham-ECT (n = 19) (age = 37.40 ± 9.62, males = 77.5 %, illness duration = 14.95 ± 8.32 years, mean total Positive and Negative Syndrome Scale (PANSS) = 101.10 ± 24.91) who fulfilled well-defined CRS criteria including baseline clozapine plasma levels ≥350 ng/mL. The primary outcome was the ≥50 % PANSS Total Score reduction; secondary outcomes were the scores of the PANSS subscales, PANSS five-factor dimensions, PANSS-6 and the Calgary Depression Rating Scale (CDRS). Treatment response was analyzed by percentage reduction, Linear Mixed Models and effect sizes. At baseline both groups showed no differences except for years of school education (included as a covariate). At endpoint, only 1/19 of the completers (5.26 %) in the ECT group and 0/17 in the sham-ECT group showed a ≥50 % total PANSS score reduction. Both groups showed no significant differences of the total PANSS score (F = 0.12; p = 0.73), Positive (F = 0.27, p = 0.61), Negative (F = 0.25, p = 0.62), and General Psychopathology scores (F = 0.01, p = 0.94) as well for all PANSS five factors, the PANSS-6 and CDRS. Thus, the present study found no evidence that ECT is better than Sham-ECT in patients with CRS. Future sham-ECT controlled studies with larger sample sizes are warranted to test the efficacy of ECT for patients with CRS.

Association between homotopic connectivity and clinical symptoms in first-episode schizophrenia

Background

Abnormal functional connectivity (FC) in the brain has been observed in schizophrenia patients. However, studies on FC between homotopic brain regions are limited, and the results of these studies are inconsistent. The aim of this study was to compare homotopic connectivity between first-episode schizophrenia (FES) patients and healthy subjects and assess its correlation with clinical symptoms.

Methods

Thirty-one FES patients and thirty-three healthy controls (HC) were included in the study. The voxel-mirrored homotopic connectivity (VMHC) method of resting-state functional magnetic resonance imaging (rs-fMRI) was used to analyse the changes in homotopic connectivity between the two groups. The 5-factor PANSS model was used to quantitatively evaluate the severity of symptoms in FES patients. Partial correlation analysis was used to assess the correlation between homotopic connectivity changes and clinical symptoms.

Results

Compared to those in the HC group, VMHC values were decreased in the paracentral lobule (PL), thalamus, and superior temporal gyrus (STG) in the FES group (P < 0.05, FDR correction). No significant differences in white matter volume (WMV) within the subregion of the corpus callosum or in brain regions associated with reduced VMHC were observed between the two groups. Partial correlation analyses revealed that VMHC in the bilateral STG of FES patients was positively correlated with negative symptoms (rleft = 0.46, p < 0.05; rright = 0.47, p < 0.05), and VMHC in the right thalamus was negatively correlated with disorganized/concrete symptoms (rright = 0.45, p < 0.05).

Conclusion

Our study revealed that homotopic connectivity is altered in the resting-state brain of FES patients and correlates with the severity of negative symptoms; this change may be independent of structural changes in white matter. These findings may contribute to the development of the abnormal connectivity hypothesis in schizophrenia patients.

Negative symptoms and sex differences in first episode schizophrenia: What's their role in the functional outcome? A longitudinal study

INTRODUCTION

Negative symptoms (NS) include asociality, avolition, anhedonia, alogia, and blunted affect and are linked to poor prognosis. It has been suggested that they reflect two different factors: diminished expression (EXP) (blunted affect and alogia) and amotivation/pleasure (MAP) (anhedonia, avolition, asociality). The aim of this article was to examine potential sex differences among first-episode schizophrenia (FES) patients and analyze sex-related predictors of two NS symptoms factors (EXP and MAP) and functional outcome.

MATERIAL AND METHODS

Two hundred and twenty-three FES (71 females and 152 males) were included and evaluated at baseline, six-months and one-year. Repeated measures ANOVA was used to examine the effects of time and sex on NS and a multiple linear regression backward elimination was performed to predict NS factors (MAP-EXP) and functioning.

RESULTS

Females showed fewer NS (p=0.031; Cohen's d=-0.312), especially those related to EXP (p=0.024; Cohen's d=-0.326) rather than MAP (p=0.086), than males. In both male and female group, worse premorbid adjustment and higher depressive symptoms made a significant contribution to the presence of higher deficits in EXP at one-year follow-up, while positive and depressive symptoms predicted alterations in MAP. Finally, in females, lower deficits in MAP and better premorbid adjustment predicted better functioning at one-year follow-up (R2=0.494; p<0.001), while only higher deficits in MAP predicted worse functioning in males (R2=0.088; p=0.012).

CONCLUSIONS

Slightly sex differences have been found in this study. Our results lead us to consider that early interventions of NS, especially those focusing on motivation and pleasure symptoms, could improve functional outcomes.

Gut and oral microbiome modulate molecular and clinical markers of schizophrenia-related symptoms: A transdiagnostic, multilevel pilot study

Although increasing evidence links microbial dysbiosis with the risk for psychiatric symptoms through the microbiome-gut-brain axis (MGBA), the specific mechanisms remain poorly characterized. In a diagnostically heterogeneous group of treated psychiatric cases and nonpsychiatric controls, we characterized the gut and oral microbiome, plasma cytokines, and hippocampal inflammatory processes via proton magnetic resonance spectroscopic imaging (1H-MRSI). Using a transdiagnostic approach, these data were examined in association with schizophrenia-related symptoms measured by the Positive and Negative Syndrome Scale (PANSS). Psychiatric cases had significantly greater heterogeneity of gut alpha diversity and an enrichment of pathogenic taxa, like Veillonella and Prevotella, in the oral microbiome, which was an accurate classifier of phenotype. Cases exhibited significantly greater positive, negative, and general PANSS scores that uniquely correlated with bacterial taxa. Strong, positive correlations of bacterial taxa were also found with cytokines and hippocampal gliosis, dysmyelination, and excitatory neurotransmission. This pilot study supports the hypothesis that the MGBA influences psychiatric symptomatology in a transdiagnostic manner. The relative importance of the oral microbiome in peripheral and hippocampal inflammatory pathways was highlighted, suggesting opportunities for probiotics and oral health to diagnose and treat psychiatric conditions.

Clinical predictors of antipsychotic treatment resistance: Development and internal validation of a prognostic prediction model by the STRATA-G consortium

INTRODUCTION

Our aim was to, firstly, identify characteristics at first-episode of psychosis that are associated with later antipsychotic treatment resistance (TR) and, secondly, to develop a parsimonious prediction model for TR.

METHODS

We combined data from ten prospective, first-episode psychosis cohorts from across Europe and categorised patients as TR or non-treatment resistant (NTR) after a mean follow up of 4.18 years (s.d. = 3.20) for secondary data analysis. We identified a list of potential predictors from clinical and demographic data recorded at first-episode. These potential predictors were entered in two models: a multivariable logistic regression to identify which were independently associated with TR and a penalised logistic regression, which performed variable selection, to produce a parsimonious prediction model. This model was internally validated using a 5-fold, 50-repeat cross-validation optimism-correction.

RESULTS

Our sample consisted of N = 2216 participants of which 385 (17 %) developed TR. Younger age of psychosis onset and fewer years in education were independently associated with increased odds of developing TR. The prediction model selected 7 out of 17 variables that, when combined, could quantify the risk of being TR better than chance. These included age of onset, years in education, gender, BMI, relationship status, alcohol use, and positive symptoms. The optimism-corrected area under the curve was 0.59 (accuracy = 64 %, sensitivity = 48 %, and specificity = 76 %).

IMPLICATIONS

Our findings show that treatment resistance can be predicted, at first-episode of psychosis. Pending a model update and external validation, we demonstrate the potential value of prediction models for TR.

Complete blood count inflammatory markers in treatment-resistant schizophrenia: Evidence of association between treatment responsiveness and levels of inflammation

Accumulating evidence suggests that the variable response to antipsychotic treatment in schizophrenia reflects distinct biological subtypes. The pathophysiology of schizophrenia is associated with alteration in the immune system which can be measured with complete blood count (CBC) markers of systemic inflammation, including the neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR). While previous research suggested a decrease in CBC inflammatory markers following treatment, it is unknown if treatment or response to treatment is associated with CBC markers in treatment-resistant schizophrenia. Here, we retrospectively analyzed the CBC at admission and discharge in schizophrenia inpatients classified as treatment-responsive, treatment-resistant, and ultra-treatment-resistant. Despite similar NLR at admission, the subtypes manifested different changes in NLR during treatment resulting in significant differences at discharge. Only the treatment-responsive group presented a significant decrease in inflammatory markers after treatment. Additionally, we found that the responsive group had a higher PLR at admission and was the only subgroup to demonstrate a significant reduction following treatment. In sum, our results support the idea that persistent inflammation is a biological trait marker of treatment resistance in schizophrenia.

Prevalence, Influencing Factors, and Clinical Characteristics of Cognitive Impairment in Elderly Patients With Schizophrenia

AIMS

The purpose of this study was to investigate the prevalence, influencing factors, and clinical characteristics of cognitive impairment in elderly patients with chronic schizophrenia.

MATERIALS AND METHODS

A total of 264 elderly patients with chronic schizophrenia and 156 normal controls were enrolled in the current study. The Mini-mental State Examination (MMSE) was used to assess their overall cognitive function, the Positive And Negative Syndrome Scale (PANSS) was used to assess their psychotic symptoms, the Geriatric Depression Scale (GDS) was used to assess their depressive symptoms, while Activity of Daily Living Scale (ADL) was used to assess their daily living ability.

RESULTS

The prevalence of cognitive impairment was 77.7% (205/264) in elderly patients with chronic schizophrenia, which was much higher than that [16.7% (26/156)] in normal controls. By using stepwise binary regression analysis, we found that hobbies (p < 0.001, OR = 0.224, 95% CI: 0.114-0.441) might be a protective factor for cognitive impairment, and this relationship remained statistically significant after adjusting for total scores of GDS, ADL and PANSS (model ^b ) (p = 0.016, OR = 0.406, 95% CI: 0.195-0.847). Compared with individuals without cognitive impairment, individuals with cognitive impairment tend to have more depression and psychiatric symptoms as well as worse activities of daily living (p < 0.05). Through linear regression analysis of the mediating model, we found that hobbies may improve cognitive function by improving psychiatric symptoms, and play a partial mediating role (B = -4.789, p < 0.001).

CONCLUSION

Cognitive impairment is a very prominent problem in elderly patients with chronic schizophrenia. Elderly schizophrenia patients with cognitive impairment tended to have more depressive mood, more psychotic symptoms and worse activities of daily living. Hobbies will help prevent cognitive impairment in elderly patients with schizophrenia and may improve their cognitive function by influencing psychiatric symptoms. Therefore, we should encourage elderly patients with chronic schizophrenia to develop their own hobbies. However, the above conclusion still need to be further verified, as we cannot exclude the effects of age and education.

Cognitive outcomes after tDCS in schizophrenia patients with prominent negative symptoms: Results from the placebo-controlled STARTS trial

Cognitive deficits and negative symptoms in schizophrenia are associated with poor functional outcomes and limited in terms of treatment. The Schizophrenia Treatment With Electric Transcranial Stimulation (STARTS) trial has shown efficacy of transcranial direct current stimulation (tDCS) for improving negative symptoms. In this secondary analysis, we investigate its effects on cognitive performance. In STARTS, a double-blinded, sham-controlled, randomized clinical trial, patients were treated with twice-daily, 20-min, 2-mA fronto-temporal tDCS over 5 days or sham-tDCS. In 90 patients, we evaluated the cognitive performance up to 12 weeks post-treatment. We found that active-tDCS showed no beneficial effects over sham-tDCS in any of the tests. Based on a 5-factor cognitive model, improvements of executive functions and delayed memory were observed in favor of sham-tDCS. Overall, the applied active-tDCS protocol, primarily designed to improve negative symptoms, did not promote cognitive improvement. We discuss possible protocol modification potentially required to increase tDCS effects on cognition. ClinicalTrials.gov identifier: NCT02535676.

Prevalence, Influencing Factors, and Cognitive Characteristics of Depressive Symptoms in Elderly Patients with Schizophrenia

PURPOSE

To investigate the prevalence, influencing factors, and cognitive characteristics of depressive symptoms in elderly patients with chronic schizophrenia.

PATIENTS AND METHODS

A total of 241 elderly patients with chronic schizophrenia and 156 healthy controls were enrolled in this study. The Geriatric Depression Scale (GDS) was used to assess depressive symptoms; the Positive and Negative Syndrome Scale was used to assess psychotic symptoms; and both the Mini-Mental State Examination and Montreal Cognitive Assessment were used to assess overall cognitive function, while the Activity of Daily Living Scale was used to assess daily living ability.

RESULTS

The prevalence of depressive symptoms was 48.5% (117/241) in elderly patients with chronic schizophrenia, which was substantially higher than that of normal controls (17.3%, 27/156). Using a stepwise binary logistic regression analysis, we found that high education (p=0.006, odds ratio [OR]=1.122, 95% confidence interval [CI]:1.034-1.218) and hypertension (p=0.019, OR=0.519, 95% CI: 0.300-0.898) were influencing factors for the comorbidity of depressive symptoms. Compared with individuals without depressive symptoms, individuals with depressive symptoms usually display worse overall cognitive function and more severe impairment of activities of daily living, but fewer psychotic symptoms. Interestingly, the GDS score was negatively correlated with the course of the disease (r=-0.157, p=0.016), suggesting that patients who had recently been admitted to the hospital were more likely to develop depression.

CONCLUSION

Elderly patients with chronic schizophrenia are often associated with higher levels of depression. Therefore, their overall cognitive function is worse, and their activities of daily living are more seriously impaired. Therefore, these patients should be provided with appropriate psychological comfort, especially those who have recently been admitted to the hospital.