Allostatic load is associated with psychotic symptoms and decreases with antipsychotic treatment in patients with schizophrenia and first-episode psychosis

Lower levels of positive affect and insomnia are associated with elevated allostatic load among Ukrainian refugees

To date, several biological alterations associated with the refugee status have been investigated. However, none of them has focused on the allostatic load (AL) index that is a collective measure of biological responses to stress. Therefore, the present study aimed to assess the AL index and its correlates in 60 Ukrainian refugees who migrated to Poland after the Russian invasion. The AL index was measured in 60 Ukrainian refugees and 50 controls matched for age and sex. It was based on sex-specific distributions of 15 biomarkers (cardiovascular markers, anthropometric measures, inflammatory markers, glucose homeostasis parameters, lipids, and steroids). Psychopathological symptoms and behavioral characteristics were assessed using self-reports. Refugees had significantly higher AL index together with higher scores of insomnia, negative affect, depressive and anxiety symptoms, avoidance and hyperarousal symptoms of post-traumatic stress disorder as well as lower levels of positive affect. Similarly, a lifetime exposure to traumatic stressors was significantly higher among Ukrainian refugees. Linear regression analyses demonstrated that lower levels of positive affect (interactive effects with the refugee status but not main associations) and higher levels of insomnia (interactive effects with the refugee status and main associations) were associated with elevated AL index after adjustment for age, education, cigarette smoking status, somatic disease, medication use, and head trauma history. In summary, the findings indicate systemic dysregulations of biological stress responses in Ukrainian refugees that are attributable to higher levels of insomnia and lower levels of positive affect in this population.

Do biological alterations precede the onset of psychosis? A systematic review and meta-analysis of immune, cardiometabolic, prolactin and HPA axis alterations in clinical high-risk for psychosis

First episode psychosis (FEP) individuals show biological abnormalities preceding antipsychotic treatment. However, it remains unclear whether such alterations are also present before the onset of psychosis. We aim to provide estimates of standardized mean differences for immune, cardiometabolic, prolactin, and HPA axis parameters in individuals at clinical high-risk for psychosis (CHR-P) compared to healthy controls (HC) and FEP individuals, and between CHR-P transitioning to psychosis (CHR-T) compared non-transitioning (CHR-NT). A multistep literature search was performed from database inception until September 25, 2023. PRISMA/MOOSE-compliant and pre-registered (PROSPERO: CRD42024507670) systematic review identified studies reporting on immune, cardiovascular or endocrine parameters in CHR-P samples compared with HC or FEP samples or comparing CHR-T vs CHR-NT. Inter-group differences in magnitude of effect were estimated using Hedges g and estimates were pooled using random-effects meta-analysis. Heterogeneity was high for most outcomes. 37 studies were included, total sample 2509 CHR-P, 710 FEP, and 1444 HC individuals. A statistically significant elevation of pro-inflammatory proteins was found among CHR-P compared with HC (k = 12; N = 1710; g = 0.16; p < 0.01) and FEP (k = 7; g = 0.15; p = 0.04) subjects. Interleukin-6 (IL-6) was increased in CHR-P compared to HC (k = 9; N = 1243; g = 0.54; p < 0.01), and interleukin-4 (IL-4) was increased in CHR-T compared with CHR-NT (k = 2; N = 318; g = 0.36; p < 0.01). CHR-P exhibited stronger cortisol awakening response than FEP subjects (k = 3; N = 173; g = 0.51; p = 0.01). CHR-P and FEP individuals did not show statistically significant differences in terms of prolactin levels. An inflammatory state (particularly marked by elevated IL-6 and IL-4 levels) and HPA axis alterations are present in CHR-P individuals.

Effects of antidepressant type on allostatic load of male and female psychiatric outpatients

Sex differences and antidepressant use are not systematically accounted for in studies measuring physiological dysregulations associated with chronic stress and allostatic load (AL) in neuropsychiatry. Critically, assessing commonly prescribed antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) and selective serotonin and norepinephrine reuptake inhibitors (SNRIs) could help monitor potential iatrogenic effects on AL and health that are associated with prolonged antidepressant use. The objective of this exploratory analysis was to investigate how male and female psychiatric outpatients using either SSRIs or SNRIs differ in their AL indices. To achieve this, we used data from a larger project collecting administrative, medical, and biological data among psychiatric outpatients of the Anjou Clinic for Mood and Anxiety Disorders, based in Montreal, Canada (n = 116). Sociodemographic variables included age and birth-assigned sex. We calculated AL using 10 biomarkers reflecting cardiovascular (systolic blood pressure, diastolic blood pressure, pulse) and metabolic (glucose, creatinine, total cholesterol, high density lipoprotein cholesterol (HDL), total cholesterol/HDL ratio, triglycerides, body mass index) functioning. Psychiatric medications were classified using the Anatomical and Therapeutic Classification system. We found that relative to female outpatients, male outpatients showed significantly higher AL levels. In addition, relative to SSRI users, SNRI users had significantly higher AL levels. However, there were no interactions effects between birth-assigned sex and antidepressant types on AL. We discuss the potential clinical implications of our findings, as well as directions for future studies that aim to investigate AL among male and female patients using antidepressants.

Association between allostatic load and cardiac structural and functional abnormalities in young adults with serious mental disorders

OBJECTIVE

Allostatic load refers to the pathophysiological consequences of uncompensated adaptation to chronic stress. Few studies have investigated the effect of allostatic load on cardiac health in patients with serious mental disorders (SMDs), a population at high risk of cardiac mortality. Herein we evaluated associations between allostatic load and cardiac structure and function in young adults with SMDs.

METHOD

A total of 106 participants aged younger than 45 years underwent echocardiographic study, blood biochemistry examination, and blood cell count analysis. Echocardiographic imaging was conducted in accordance with recommendations of the American Society of Echocardiography and European Association of Cardiovascular Imaging. Allostatic load index was calculated using 15 measures representing cardiovascular, metabolic, and inflammatory or oxidative stress markers.

RESULTS

The SMD group exhibited a significantly higher allostatic load index than did control (Cohen's d = 0.59). Additionally, they exhibited a greater left ventricular relative wall thickness (LVRWT, Cohen's d = 0.39) and a less favorable mitral valve E/A ratio (Cohen's d = 0.31), left ventricular ejection fraction (Cohen's d = 0.51), and global longitudinal strain (Cohen's d = 0.71). After demographic and clinical characteristics were adjusted for, multiple linear regression revealed that allostatic load index was positively associated with LVRWT (β = 0.255) and negatively associated with mitral valve E/A ratio (β = -0.247) in the SMD group.

CONCLUSIONS

This is the first study to suggest that allostatic load may play a critical role in accelerated adverse cardiac remodeling among young patients with SMDs. Future studies should elucidate the underlying mechanisms.

Potential use of salivary TNF-α as a vaccine-induced pain biomarker in people with cerebral palsy and communication disorders

BACKGROUND

Pain in people with cerebral palsy (CP) has been classically underestimated and poorly treated, particularly in individuals with impaired communication skills.

OBJECTIVE

To analyze changes in different salivary metabolites and pain behavior scales after a painful procedure in adults with CP and adults with typical development.

METHODS

Salivary levels of sTNF-α, sIgA, Cortisol, FRAP, ADA and Alpha Amylase, as well as 3 observational pain scales (Wong-Baker, Non-Communicating Adults Pain Checklist and Facial Action Coding System) were assessed before and after an intramuscular injection in 30 Individuals with CP and 30 healthy controls. Video recording of face expression was performed during the procedure for offline analysis.

RESULTS

Pain in subjects with CP was higher than in healthy controls after the intramuscular injection as displayed by observational scales. sTNF-α experienced a significant post-stimulus increase in both groups and that increase shows a tendency to correlate with the observational scales scores. Other biomarkers classically associated with stress (cortisol, Alpha Amylase) remain stable.

CONCLUSION

sTNF-α might be a promising pain indicator. Further research using controlled painful stimuli of greater intensity and pain self-reports, would be necessary to better understand its use as a pain biomarker.

Schizophrenia, a disease of impaired dynamic metabolic flexibility: A new mechanistic framework

Schizophrenia is a chronic, neurodevelopmental disorder with unknown aetiology and pathophysiology that emphasises the role of neurotransmitter imbalance and abnormalities in synaptic plasticity. The currently used pharmacological approach, the antipsychotic drugs, which have limited efficacy and an array of side-effects, have been developed based on the neurotransmitter hypothesis. Recent research has uncovered systemic and brain abnormalities in glucose and energy metabolism, focusing on altered glycolysis and mitochondrial oxidative phosphorylation. These findings call for a re-conceptualisation of schizophrenia pathophysiology as a progressing bioenergetics failure. In this review, we provide an overview of the fundamentals of brain bioenergetics and the changes identified in schizophrenia. We then propose a new explanatory framework positing that schizophrenia is a disease of impaired dynamic metabolic flexibility, which also reconciles findings of abnormal glucose and energy metabolism in the periphery and in the brain along the course of the disease. This evidence-based framework and testable hypothesis has the potential to transform the way we conceptualise this debilitating condition and to develop novel treatment approaches.

Resilience as a predictor of habituation

Habituation refers to the physiological adaptation to recurrent stressors, which can be measured by cortisol levels, and is considered a central mechanism in reducing allostatic load. Resilience, a potential factor influencing stress reduction, is the focus of this study. Specifically, the study aims to investigate the impact of resilience, as assessed by the Brief Resilience Scale (BRS), on habituation. The Trier Social Stress Test (TSST) was used as the recurrent stressor, and it was administered to each of the 56 subjects at 4 consecutive measurements. To assess habituation, various physiological parameters including the area under the curve with respect to the ground (AUCg) and with respect to the increase (AUCi), cortisol peak, slope from baseline to peak, and recovery were calculated. Mixed linear models were employed to examine the differences in the influence of resilience on habituation across the different time points. The findings indicate that the influence of resilience significantly varies from the first to the fourth measurement time point for AUCg (p = .048), while no significant differences were observed for the other cortisol parameters. The effects plot suggests that individuals with higher levels of resilience exhibit lower AUCg values throughout the measurements. These findings provide initial evidence supporting resilience as a predictor of cortisol habituation. However, future studies should also consider dynamic resilience models, utilizing longitudinally assessed resilience as a predictor for habituation, to explore whether resilience acts as a determinant of habituation or if habituation itself constitutes a resilience mechanism.

Development of an anti-inflammatory diet for first-episode psychosis (FEP): a feasibility study protocol

Background

Evidence suggests inflammation plays a role in the pathophysiology of psychosis even in early illness, indicating a potential avenue for anti-inflammatory interventions that simultaneously address high rates of metabolic disease in this population. The aim of this study is to design a novel anti-inflammatory diet intervention (DI) that is feasible to implement in a first-episode psychosis (FEP) population.

Methods

Eligible FEP Participants are aged 15-30. The DI is currently being refined through a multi-phase process that includes the recruitment of focus groups that provide insight into feasibility of measures and nutritional education, as well as the implementation of the DI. The phases in the study are the Development Phase, Formative Phase, and the Feasibility Phase.

Results

The Development phase has resulted in the creation of a flexible DI for FEP based on existing research on nutritional health and informed by providers. This study has just completed the Formative phase, recruiting eligible participants to join focus groups that gleaned information about dietary habits, preferences, and food environments to further refine the DI.

Conclusion

Findings from earlier phases have advised the current Feasibility Phase in which this novel DI is being administered to a small cohort of FEP participants (N = 12) to determine acceptability of the DI from a lived experience perspective. Naturalistic changes in inflammatory biomarkers, metabolic health, and symptoms will also be measured.

Correlation of allostatic load and perceived stress with clinical features in first-episode schizophrenia

BACKGROUND

Stress plays an important role in the etiology of schizophrenia. However, the mechanisms by which chronic physiological stress and perceived stress relate to the clinical features of schizophrenia may differ. We aimed to elucidate the relationships among chronic physiological stress indexed by allostatic load (AL), perceived stress, and clinical symptoms in individuals with first-episode schizophrenia (FES).

METHODS

Individuals with FES (n = 90, mean age = 28.26years old, 49%female) and healthy controls (111, 28.88, 51%) were recruited. We collected data of 13 biological indicators to calculate the AL index, assessed subjective stress with the Perceived Stress Scale-14 (PSS-14), and compared AL and perceived stress between groups. Patients with FES were also evaluated with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS).

RESULTS

Individuals with FES had higher AL and PSS score than healthy controls. There were no significant correlations between AL and PSS score in either patients or controls. Among individuals with FES, the AL index was associated with the severity of positive symptoms, while the PSS score was positively associated with CDSS score. Both elevated AL and PSS were correlated with the occurrence of schizophrenia.

CONCLUSIONS

Physiological stress, as reflected by AL, may be more related to positive symptoms, while perceived stress appear to be associated with depressive symptoms in individuals with FES. Longitudinal studies are necessary to explore the relationships between interventions for different stressor types and specific clinical outcomes in FES.

Childhood adversity, allostatic load, and adult mental health: Study protocol using the Avon Longitudinal Study of Parents and Children birth cohort

Introduction

The cumulative burden of chronic stress and life events has been termed allostatic load. Elevated allostatic load indices are associated with different mental health conditions in adulthood. To date, however, the association between elevated allostatic load in childhood and later development of mental health conditions has not been investigated.

Methods

Using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), we will calculate allostatic load indices using biomarkers representing the cardiovascular, metabolic, immune, and neuroendocrine systems, at the ages of 9 and 17 years. Bivariate and multivariable logistic regression models will be used to investigate the association between allostatic load and psychiatric disorders in adulthood. Furthermore, the role of adverse childhood experiences as a modifier will be investigated.

Discussion

This protocol describes a strategy for investigating the association between elevated allostatic load indices in childhood at the age of 9 years old and psychiatric disorders in adulthood at 24 years old.

Allostatic Load Measurement: A Systematic Review of Reviews, Database Inventory, and Considerations for Neighborhood Research

BACKGROUND

Neighborhoods are critical to understanding how environments influence health outcomes. Prolonged environmental stressors, such as a lack of green spaces and neighborhood socioeconomic disadvantage, have been associated with higher allostatic load levels. Since allostatic load levels experienced earlier in life have stronger associations with mortality risk, neighborhoods may be uniquely suited to monitor and mitigate the impacts of environmental stressors. Researchers often study allostatic load in neighborhoods by utilizing administrative boundaries within publicly accessible databases as proxies for neighborhoods.

METHODS

This systematic review of reviews aims to identify commonly used biomarkers in the measurement of allostatic load, compare measurement approaches, inventory databases to study allostatic load, and spotlight considerations referenced in the literature where allostatic load is studied in neighborhoods. The review was conducted using the search term "allostatic load" in the MEDLINE, CINAHL, and PsychINFO databases. The search results were filtered to include reviews.

RESULTS

The search returned 499 articles after deduplication. Overall, 18 synthesis reviews met the inclusion criteria and were retained for extraction. The synthesis reviews analyzed represented 238 studies published from 1995 to 2020. The original ten biomarkers were most often used to measure allostatic load. More recently, body mass index and C-reactive protein have additionally been frequently used to measure allostatic load burden.

CONCLUSIONS

The scientific contributions of this study are that we have identified a clear gap in geographic considerations when studying allostatic load. The implication of this study is that we have highlighted geographic concepts when conducting neighborhood-level research using administrative databases as a neighborhood proxy and outlined emerging future trends that can enable future study of allostatic load in the neighborhood context.

Sex and Gender and Allostatic Mechanisms of Cardiovascular Risk and Disease

Cardiovascular diseases are leading causes of mortality and morbidity in adults worldwide. Multiple studies suggest that there are clinically relevant sex differences in cardiovascular disease. Women and men differ substantially in terms of prevalence, presentation, management, and outcomes of cardiovascular disease. To date, however, little is known about why cardiovascular disease affects women and men differently. Because many studies do not differentiate the concept of sex and gender, it is sometimes difficult to discriminate sociocultural vs biological contributors that drive observed clinical differences. Female sex has some biological advantages in relation to cardiovascular disease, but many of these advantages seem to disappear as soon as women develop cardiovascular risk factors (eg, type 2 diabetes, hypertension, dyslipidemia). Furthermore, stress and allostatic load could play an important role in the relationship between sex/gender and cardiovascular diseases. In this narrative review, we argue that chronic stress and psychosocial factors might better encompass the patterns of allostatic load increases seen in women, while biological risk factors and unhealthy behaviours might be more important mechanisms that drive increased allostatic load in men. Indeed, men show allostatic load patterns that are more associated with impaired anthropometric, metabolic, and cardiovascular functioning and women have greater dysregulation in neuroendocrine and immune functioning. Thus gender-related factors might contribute to the pathogenesis of cardiovascular disease especially through stress mechanisms. It is important to continue to study the mechanisms by which gender influences chronic stress, because chronic stress could influence modifiable gendered factors to promote cardiovascular disease prevention.

Neurodevelopmental aspects of adverse childhood experiences in psychosis: Relevance of the allostatic load concept

Previous studies have shown that neurodevelopmental characteristics of adverse childhood experiences (ACEs), such as their accumulation and minimal age at exposure, might moderate their impact on clinical expression of psychosis. However, it remains unknown as to whether specific neurodevelopmental characteristics of ACEs are associated with biological alterations observed in psychosis. In this study, we tested the hypothesis that younger minimal age at exposure as well as greater accumulation and severity of ACEs are associated with systemic biological dysregulations captured by the allostatic load (AL) index in patients with psychosis. The present study included 65 inpatients with psychotic disorders and 56 healthy controls (HCs). A total of 15 biomarkers were used to measure the AL index. Individuals with psychosis had significantly higher AL index as well as they reported greater accumulation and severity of ACEs compared to HCs. After adjustment for age, sex, the number of education years and the dosage of antipsychotics, greater accumulation of ACEs and younger minimal age at exposure were significantly associated with higher AL index in patients with psychosis. None of neurodevelopmental characteristics of ACEs was associated with the AL index in HCs. Our findings indicate that greater accumulation of ACEs and younger minimal age at exposure are related to biological dysregulations captured by the AL index in patients with psychosis. Future studies investigating the role of ACEs in the pathophysiology of psychosis need to consider their neurodevelopmental characteristics. It is also important to further explore timing of exposure to indicate critical developmental periods related to psychosis risk and better inform potential interventions.

Increased allostatic load associated with ambient air pollution acting as a stressor: Cross-sectional evidence from the China multi-ethnic cohort study

BACKGROUND

Allostatic load measures the cumulative biological burden imposed by chronic stressors. Emerging experimental evidence supports that air pollution acting as a stressor activates the neuroendocrine system and then produces multi-organ effects, leading to allostatic load. However, relevant epidemiological evidence is limited.

OBJECTIVES

We aim to explore the relationships between chronic exposure to ambient air pollution (PM₁, PM_2.5, PM₁₀, and O₃) and allostatic load in Chinese adults.

METHODS

This cross-sectional study included 85,545 participants aged 30-79 from the baseline data of the China Multi-Ethnic Cohort (CMEC). Ambient air pollution levels were evaluated by a satellite-based random forest approach. The previous three-year average exposure concentrations were calculated for each participant based on the residential address. The outcome allostatic load was identified through the sum of the sex-specific scores of twelve biomarkers belonging to four major categories: cardiovascular, metabolic, anthropometric, and inflammatory parameters. We performed statistical analysis using a doubly robust approach which relies on inverse probability weighting and outcome model to adjust for confounding.

RESULTS

Long-term exposure to ambient air pollution was significantly associated with an increased risk of allostatic load, with relative risk (95% confidence interval) of 1.040 (1.024, 1.057), 1.029 (1. 018, 1. 039), and 1.087 (1.074, 1.101) for each 10 μg/m³ increase in ambient PM_2.5, PM₁₀, and O₃, respectively. No significant relationship was observed between chronic exposure to PM₁ and allostatic load. The associations between air pollution and allostatic load are modified by some intrinsic factors and non-chemical stressors. The people with older, minority, lower education, and lower-income levels had a significantly higher allostatic load induced by air pollution.

CONCLUSIONS

Chronic exposure to ambient PM_2.5, PM₁₀, and O₃ may increase the allostatic load. This finding provides epidemiological evidence that air pollution may be a chronic stressor, leading to widespread physiological burdens.

The use of diary methods to evaluate daily experiences in first-episode psychosis

Integrated Coping Awareness Therapy (I-CAT) is an intervention that targets stress reactivity in first-episode psychosis (FEP). This study extends prior outcome research on I-CAT by examining predictors of online daily diary completion among 38 young adults with FEP and treatment group differences in diary ratings. We found no significant predictors of daily diary completion rate and no effect of treatment condition on diary ratings. These results are consistent with Halverson et al. (2021) and suggest that diaries are a valuable method of data collection in FEP.

Allostatic load and systemic comorbidities in psychiatric disorders

Psychiatric disorders are complex, disabling, and chronic conditions that are often accompanied by one or more systemic medical comorbidities. In this narrative review, we provide an overview of the allostatic load concept, which represents a multi-system dysregulation in response to chronic stress and link it to systemic comorbidities associated with psychiatric disorders. We synthesized published literature gathered using Medline (Ovid), Scopus, and PsychInfo and identified a high frequency of systemic comorbidities for both mood and psychotic disorders. The identified cardiovascular, metabolic, and immune comorbidities may represent the result of chronic wear and tear caused by a complex interaction between chronic psychosocial stress, health risk behaviors, pharmacological stressors, and the biological systems involved in the development of allostatic load. These findings support the notion that psychiatric disorders should be re-conceptualized as systemic disorders, affecting the brain and systemic biological pathways in an interconnected fashion to result in systemic comorbidities. We suggest that the multi-systemic and multi-dimensional approach that drives the allostatic load concept should be considered for understanding comorbidities in vulnerable psychiatric patients.

Schizophrenia: a disorder of broken brain bioenergetics

A substantial and diverse body of literature suggests that the pathophysiology of schizophrenia is related to deficits of bioenergetic function. While antipsychotics are an effective therapy for the management of positive psychotic symptoms, they are not efficacious for the complete schizophrenia symptom profile, such as the negative and cognitive symptoms. In this review, we discuss the relationship between dysfunction of various metabolic pathways across different brain regions in relation to schizophrenia. We contend that several bioenergetic subprocesses are affected across the brain and such deficits are a core feature of the illness. We provide an overview of central perturbations of insulin signaling, glycolysis, pentose-phosphate pathway, tricarboxylic acid cycle, and oxidative phosphorylation in schizophrenia. Importantly, we discuss pharmacologic and nonpharmacologic interventions that target these pathways and how such interventions may be exploited to improve the symptoms of schizophrenia.

Suicide: Allostatic regulation and resilience

Suicide is a complex public health problem that is the result of a number of intertwined biopsychosocial factors. The diathesis-stress model suggests that suicide is the result of an interaction between genetic vulnerability and environmental stressors. Chronic stress and trauma contribute to biologic adaptations, including hypothalamus-pituitary-adrenal axis dysregulation, that contribute to the degradation of regulatory mechanisms and promote wear and tear the body, represented by allostatic load (AL). AL has been associated with a number of negative outcomes, including mental health problems and suicide. Fortunately, there are pharmacological and non-pharmacological interventions that are effective at reducing AL and reversing its effects. Thus, AL may provide a construct for supporting early risk identification, prevention, and treatment of suicide. AL biomarkers that are amenable to measurable change, effective treatments to reduce AL and perhaps help prevent suicide, and how to best tailor them to the individual and societal levels are important avenues of therapeutic inquiry.

Adverse childhood experiences and allostatic load: A systematic review

Adverse Childhood Experiences (ACEs) are stressful and/or traumatic experiences associated with an increased lifetime risk of negative health outcomes. The Allostatic Load (AL) is a measure of multisystem dysregulation, resulted by chronic stress. We systematically reviewed the English language literature on the association between ACEs and AL to identify the clinical risk profile, with the exclusion of reviews and preclinical studies. Searches covered the publication period up to the 1^st of February 2022 and identified 25 studies in which ACEs such as maltreatment, abuse, poverty, psychological abuse, and discrimination were investigated in the context of AL. The selected studies used different sets of AL biomarkers resulting in substantial heterogenicity of calculating the AL index. Overall, we found that ACEs are associated with elevated AL and poorer health outcomes in adulthood. Furthermore, health risk behaviors, social support, and coping resources either moderate or mediate this association. These findings suggest that targeting individuals at risk and starting interventions early might reduce AL and its deleterious health consequences.

Adverse childhood experiences and low socioeconomic status with respect to allostatic load in adulthood: A systematic review

Early-life psychosocial stress primes a number of health risk behaviors, and contributes to the development of various mental and somatic disorders in adulthood. It has been reported that adverse childhood experiences (ACEs) and low socioeconomic status (SES) might be associated with allostatic load (AL) in adulthood. In turn, elevated AL index has been found to predict a number of unfavorable health outcomes. Therefore, we aimed to perform a systematic review of studies investigating the association of ACEs and childhood SES with AL in adult populations. Independent online searches covered the publication period up to 20th Jun 2021. A total of 27 studies were included in qualitative synthesis. The majority of eligible studies showed that ACEs (14 out of 19 studies recording ACEs, 73.7%) and low childhood SES (11 out of 12 studies recording childhood SES, 91.7%) are associated with elevated AL in adults. However, several processes were found to mediate or moderate this association. These include educational attainments, social support, health behaviors, adult stress, post-traumatic stress disorder, coping strategies and aging. Moreover, a substantial methodological heterogeneity of approaches to calculating the AL index was observed. Apart from reports from overlapping samples, none of eligible studies used the same set of biomarkers. Findings from this systematic review imply that early-life psychosocial stress might have a lasting impact on biological dysregulations captured by the AL index. Future studies need to explore whether the association between early-life stress and the AL index accounts for the development of specific health outcomes.

Heightened risk factors in the midst of the pandemic: Supporting individuals with psychosis during COVID-19

PURPOSE

This article aims to describe distinct vulnerabilities to the psychosocial stress from coronavirus disease 2019 (COVID-19) on individuals with psychosis and provide practical ways to reduce the vulnerabilities.

CONCLUSION

Societal changes and stress have come in the wake of the COVID-19. Individuals with psychosis are more susceptible to stress, cognitive biases, and lack social support. Practitioners working with individuals with psychosis are in a unique position to offer ways to reduce risk.

PRACTICE IMPLICATIONS

Care during the pandemic requires practitioners to pay particular attention to magnified risk factors to individuals with psychosis and create a plan to offer adjunct support.

Allostatic Load and Its Impact on Health: A Systematic Review

INTRODUCTION

Allostatic load refers to the cumulative burden of chronic stress and life events. It involves the interaction of different physiological systems at varying degrees of activity. When environmental challenges exceed the individual ability to cope, then allostatic overload ensues. Allostatic load is identified by the use of biomarkers and clinical criteria.

OBJECTIVE

To summarize the current knowledge on allostatic load and overload and its clinical implications based on a systematic review of the literature.

METHODS

PubMed, PsycINFO, Web of Science, and the Cochrane Library were searched from inception to December 2019. A manual search of the literature was also performed, and reference lists of the retrieved articles were examined.We considered only studies in which allostatic load or overload were adequately described and assessed in either clinical or non-clinical adult populations.

RESULTS

A total of 267 original investigations were included. They encompassed general population studies, as well as clinical studies on consequences of allostatic load/overload on both physical and mental health across a variety of settings.

CONCLUSIONS

The findings indicate that allostatic load and overload are associated with poorer health outcomes. Assessment of allostatic load provides support to the understanding of psychosocial determinants of health and lifestyle medicine. An integrated approach that includes both biological markers and clinimetric criteria is recommended.

Enhancing stress reactivity and wellbeing in early schizophrenia: A randomized controlled trial of Integrated Coping Awareness Therapy (I-CAT)

Individuals with schizophrenia spectrum disorders (SSD) are at heightened risk for exposure to stressful life events which can lead to increased sensitivity to stress and a dysregulated stress response, which are in turn associated with poor long-term functioning. Stress reactivity is thus a promising treatment target in the early stages of SSD. Integrated-Coping Awareness Therapy (I-CAT) is a manualized intervention integrating mindfulness and positive psychology to target a dysregulated stress response in SSD. The current study is a preliminary randomized-controlled trial (RCT) comparing I-CAT (n = 18) with treatment as usual (TAU; n = 18) in individuals in the early stages of SSD. I-CAT was hypothesized to be more effective than TAU on primary outcomes: increasing positive emotions, decreasing negative emotions, reducing stress, and improving functioning and quality of life; and secondary outcomes: reducing symptoms, increasing mindfulness, and improving overall well-being. Excellent therapy attendance rates, low study attrition, and positive participant feedback demonstrated that I-CAT was a feasible and well-tolerated psychosocial intervention. Results suggest I-CAT led to greater reduction in symptoms (i.e., overall, negative, and disorganized symptoms), increased observational mindfulness, increased endorsement of a sense of purpose in life, and preservation of work abilities and school social functioning compared with TAU. Future work should replicate and extend these findings in a larger-scale RCT.

Aberrant anterior cingulate processing of anticipated threat as a mechanism for psychosis

Stress and abnormal stress response are associated with schizophrenia spectrum disorder (SSD), but the brain mechanisms linking stress to symptomatology remain unclear. In this study, we used a stress-based functional neuroimaging task, reverse-translated from preclinical studies, to test the hypothesis that abnormal corticolimbic processing of stressful threat anticipation is associated with psychosis and affective symptoms in SSD. Participants underwent an MRI-compatible ankle-shock task (AST) in which the threat of mild electrical shock was anticipated. We compared functional brain activations during anticipatory threat periods from N = 18 participants with SSD (10 M/8F) to those from N = 12 community controls (9 M/3F). After family-wise error correction, only one region, the ventral anterior cingulate cortex (vACC), showed significantly reduced activation compared with controls. vACC activation significantly correlated with clinical symptoms measured by the Brief Psychiatric Rating Scale total score (r = 0.54) and the psychosis subscale (r = 0.71), and inversely correlated with trait depression measured by the Maryland Trait and State Depression scale (r=-0.48). Deficient activation in vACC under stress of anticipated threat may lead to aberrant interpretation of such threat, contributing to psychosis and mood symptoms in SSD. This experimental paradigm has translational potential and may identify circuitry-level mechanisms of stress-related mental illness, leading to more targeted treatment.

Allostatic Load Effects on Cortical and Cognitive Deficits in Essentially Normotensive, Normoweight Patients with Schizophrenia

Reduced cortical gray matter integrity and cognitive abilities are among core deficits in schizophrenia. We hypothesized that higher allostatic load (AL) that accounts for exposure to chronic stress is a contributor to structural and cognitive deficits in schizophrenia. One hundred and sixty-seven schizophrenia patients who were on average with normal weight, normal systolic, and diastolic blood pressure and 72 healthy controls were enrolled in the study. Group differences in subclinical cardiovascular, metabolic, immune, and neuroendocrine biological markers as indexed by AL and contribution of AL components to the structural and cognitive deficits in schizophrenia were explored. Compared with controls, schizophrenia patients who were normotensive, normoweight, and had low total cholesterol levels still had significantly higher AL mainly due to lower high-density lipoprotein cholesterol and higher heart rate, waist-hip ratio, hemoglobinA1c, hypersensitive C-reactive protein, and overnight-urine cortisol levels. Patients also had decreased whole-brain mean cortical thickness, and lower cognition assessed by the MATRICS consensus cognitive battery. AL was inversely correlated with mean cortical thickness and cognition in schizophrenia, while none of these relationships existed in controls. Mediation analyses showed the effect of AL on cognitive deficits in schizophrenia was significantly mediated by cortical thinning, and the most significant mediating cortical area was the left superior frontal gyrus. Cortical thickness may act as a mediator between AL and cognitive deficits in schizophrenia. Early intervention strategies to reduce cortical thinning and cognitive dysfunction in schizophrenia should target specific aspects of their high AL in addition to weight gain, hypertension and high cholesterol levels.

Allostatic load and mental health: a latent class analysis of physiological dysregulation

This study explored the associations between specific profiles of biological dysregulation and mental health outcomes in a national, community sample of healthy adults in the United States. A latent class analysis of data from the Midlife Development in the United States study (n = 1,757) was conducted to determine classes of biological dysregulation. Multinomial logistic regressions of class membership were employed to determine associations with measures related to depression, including whether or not individuals had sought treatment, Center for Epidemiological Studies Depression Scale, and both the generalized distress and anhedonia subscales of the Mood and Anxiety Symptoms Questionnaire. Four classes of dysregulation emerged: baseline/low dysregulation, metabolic and inflammatory dysregulation, parasympathetic dysregulation, and SAM pathway dysregulation. Individuals who met the criteria for depression measures were more likely to be in the metabolic and immune dysregulation and parasympathetic dysregulation groups as compared to the baseline group. The results suggest that mental health outcomes, such as depression, are differentially associated with specific profiles of biological dysregulation. A more nuanced approach to profiles of dysregulation could better inform treatment decisions.Lay summaryHigher levels of allostatic load, which represents the cumulative wear and tear of exposure to stress, are associated with increased rates of depression and anhedonia. Specifically, parasympathetic dysregulation and immunometabolic dysregulation are associated with negative mental health outcomes.

A meta-analysis of blood and salivary cortisol levels in first-episode psychosis and high-risk individuals

Dysregulated cortisol responses and glucose metabolism have been reported in psychosis. We performed a random-effects meta-analysis of cortisol responses in first-episode psychosis (FEP) and psychosis risk states, taking into consideration glucose metabolism. A total of 47 studies were included. Unstimulated blood cortisol levels were significantly higher (g = 0.48, 95 %CI: 0.25-0.70, p < 0.001) in FEP, but not in psychosis risk states (g = 0.39, 95 %CI: -0.42-1.21, p = 0.342), compared to controls. Cortisol awakening response (CAR) was attenuated in FEP (g = -0.40, 95 %CI: -0.68 - -0.12, p = 0.006), but not in psychosis risk states (p = 0.433). Glucose and insulin levels were positively correlated with unstimulated blood cortisol levels in FEP. Our meta-analysis supports previous findings of elevated blood cortisol levels and attenuated CAR in FEP. Future research should focus on identifying the common denominators for alterations in stress hormones and glucose metabolism.

Relationship between allostatic load and clinical outcomes in youth at ultra-high risk for psychosis in the NEURAPRO study

Individuals at ultra-high risk (UHR) for psychosis have an elevated risk of developing psychosis and other psychiatric outcomes. Risk biomarkers can assist in delineating individual risk and allow better prediction of longer-term outcomes. The aim of the present study was to examine if allostatic load (AL), a multisystem index of neuroendocrine, cardiovascular, immune and metabolic dysregulation, is associated with clinical outcomes in youth at UHR for psychosis. AL was measured in 106 participants of the NEURAPRO study (n = 70 female, n = 36 male; mean age 17.21, SD 2.37), a multicentre randomized-controlled trial of long-chain omega-3 polyunsaturated fatty acids versus placebo in people at UHR for psychosis. Psychiatric symptoms and social and occupational functioning were assessed at baseline and 6 and 12 months after study intake. Multivariate linear and logistic regression models were used to test the relationship between AL and clinical outcomes. High AL at baseline was associated with poor social and occupational functioning at 6 months (β = -0.224, p = 0.025) and with more severe manic symptoms at 6 months (β = 0.207, p = 0.026), taking into account relevant covariates including age and smoking status. No significant associations were observed at the 12-month follow-up assessment or with any other clinical outcome measures. Our data provide initial evidence for a link between AL and impaired functioning in individuals at UHR for psychosis. Further studies are needed to evaluate AL as a potential predictor of early treatment response.

Allostatic load, emotional hyper-reactivity, and functioning in individuals with bipolar disorder

OBJECTIVES

Diagnosis and management of bipolar disorder (BD) are limited by the absence of available biomarkers. Allostatic load (AL) represents the strain that stress, including the effects of acute phases and inter-episode chronic mood instability, exerts on interconnected biological systems. This study aimed to operationalize an AL index and explore whether it could be relevant to better characterize BD patients with and without emotional hyper-reactivity particularly those at higher risk of immune-cardiometabolic dysregulation and functional impairment.

METHODS

Levels of biomarkers of chronic inflammation (hsCRP and albumin), cardiovascular (systolic/diastolic blood pressure) and metabolic functions (fasting glucose, glycosylated hemoglobin, total cholesterol, LDL, HDL, and triglycerides) were measured in 1072 adult BD outpatients. Patients were classified in two groups (with/without emotional hyper-reactivity) assessed by the Multidimensional Assessment of Thymic States scale. An Allostatic Load Index for BD (BALLI), comprising six biomarkers, was constructed using data-driven biomarker selection.

RESULTS

BALLI showed 81.1% accuracy with good sensitivity (81%) and specificity (81.2%) for characterizing BD patients presenting emotional hyper-reactivity, elevated risk of inflammation (increased hsCRP, hypoalbuminemia) and cardiometabolic disturbances (hypertension, hyperglycemia, and hypertriglyceridemia). Patients classified by the BALLI as presenting emotional hyper-reactivity had significantly lower global and cognitive functioning than those without emotional hyper-reactivity (P < .0001).

CONCLUSIONS

A multidimensional approach based on a simple AL score (eg, BALLI) and dimensions of behavior (eg, emotional hyper-reactivity) alongside mood is clinically relevant. AL index could be a useful tool to detect multisystemic physiological dysregulations in BD patients with/without emotional hyper-reactivity particularly those at higher risk of immune-cardiometabolic disturbances and functional impairment.

Does the choice of Allostatic Load scoring algorithm matter for predicting age-related health outcomes?

Allostatic Load (AL) is posited to provide a measure of cumulative physiological dysregulation across multiple biological systems and demonstrates promise as a sub-clinical marker of overall health. Despite the large heterogeneity of measures employed in the literature to represent AL, few studies have investigated the impact of different AL scoring systems in predicting health. This study uses data for 4477 participants aged 50+ years participating in the Irish Longitudinal Study on Ageing (TILDA) to compare the utility of 14 different scoring algorithms that have been used to operationalise AL (i.e. count-based high-risk quartiles, deciles, two-tailed cut-points, z-scores, system-weighted indices, clinical cut-points, sex-specific scores, and incorporating medication usage). Model fit was assessed using R², Bayesian Information Criterion (BIC), and the area under the Receiver Operating Characteristic curve (AUC). The measure incorporating medications predicted walking speed and SRH marginally better than others. In general, AL was not predictive of grip strength. Overall, the results suggest that the choice of AL scoring algorithm exerts a relatively modest influence in predicting a number of important health outcomes.

A scoping review of interventions targeting allostatic load

Allostatic load (AL) is the manifestation of cumulative responses to chronic stress exposure. Numerous studies have shown the importance of AL in understanding disease risks. Yet little is known about existing interventions that target AL specifically. We aimed to address this gap by identifying interventions targeting AL and determining the success of these interventions in improving biological functioning. We searched five electronic databases using variations of two concepts: AL and programs or interventions. We included original research reports that focused on AL as an outcome. We excluded work that focused on a single indicator, not written in English or did not implement an intervention. The Template for Intervention Description and Replication checklist guided our intervention critique and synthesis. Six articles were included, with sample size across the interventions ranging between 2 and 733. Despite inconsistencies in the selection of AL indicators and scoring of AL, all four body systems were represented in all the studies. Four interventions showed significant improvement in Al (as indicated by a decrease in AL score) as early as 7 weeks. More interventions targeting Al are needed. The reduction in AL scores among four of the six interventions suggests that Al could be a biological outcome measure that is sensitive to change in response to interventions. This has significant clinical and research implications. Future studies are needed to examine whether AL serves as a mediator in the effects of the intervention on improving clinical manifestations of diseases.

Stress, allostatic load and mental health in Indigenous Australians

The aim of this narrative review was to demonstrate how the notion of allostatic load (AL) relates directly to the mental health disparities observed between Indigenous and non-Indigenous Australians. We also endeavored to synthesize the results of the limited number of studies examining stress and AL in Indigenous Australians in order to explore the potential public health benefits of the AL concept. A range of literature examining health inequalities, psychosocial determinants of mental illness and AL was explored to demonstrate the applicability of stress biology to the significant mental health burden faced by Indigenous Australians. Furthermore, all original studies indexed in MEDLINE that provided quantitative data on primary stress biomarkers in Indigenous Australians were selected for review. Evidence of hypothalamic-pituitary-adrenal axis dysregulation and increased AL is apparent even in the handful of studies examining stress biomarkers in Indigenous Australians. Urinary, salivary, hair and fingernail cortisol, hair cortisone, urinary epinephrine, heart rate variability and the cortisol awakening response are all AL parameters which have been shown to be dysregulated in Indigenous Australian cohorts. Furthermore, associations between some of these biomarkers, self-perceived discrimination, exposure to stressful life events and symptoms of psychiatric disorders in Indigenous Australians have also been demonstrated. The continued assessment of AL biomarkers and their relationship with past traumas, lifetime stressors and socio-economic factors amongst Indigenous Australians is important to addressing the mental health this population. Measurement of AL biomarkers in a culturally appropriate manner may lead to more targeted preventative measures, interventions and policies, which mitigate the effects of stress at both the individual and societal level.

Accumulation rate of advanced glycation end products in recent onset psychosis: A longitudinal study

Schizophrenia is associated with excessive oxidative stress. Production of advanced glycation end products (AGEs) in the skin is strongly associated with oxidative stress. Increased skin AGE-levels have been demonstrated at cross-sectional level in recent onset psychosis and chronic schizophrenia, indicating increased cardiovascular risk. We aimed to investigate factors underlying AGE-accumulation and accumulation rate of AGEs in recent onset psychosis. From December 2016 through May 2017, 66 patients and 160 (highly educated) healthy controls from a previous case-control study of AGE-levels were assessed for a follow-up measurement 12-24 months after baseline. Possible determinants of AGE-accumulation were analyzed. AGE-accumulation rates in patients and controls were compared adjusted for relevant confounders. In healthy controls, a significant association of AGE-accumulation with ethnicity and tobacco exposure was found. An indication of a markedly higher AGE-accumulation rate was found in patients suffering from recent onset psychosis compared to healthy controls, independent of ethnicity and tobacco smoking, but not independent of cannabis use (more prevalent in patients than controls), although results were not significant.

The Gut Microbiome in Psychosis From Mice to Men: A Systematic Review of Preclinical and Clinical Studies

The gut microbiome is rapidly becoming the focus of interest as a possible factor involved in the pathophysiology of neuropsychiatric disorders. Recent understanding of the pathophysiology of schizophrenia emphasizes the role of systemic components, including immune/inflammatory and metabolic processes, which are influenced by and interacting with the gut microbiome. Here we systematically review the current literature on the gut microbiome in schizophrenia-spectrum disorders and in their animal models. We found that the gut microbiome is altered in psychosis compared to healthy controls. Furthermore, we identified potential factors related to psychosis, which may contribute to the gut microbiome alterations. However, further research is needed to establish the disease-specificity and potential causal relationships between changes of the microbiome and disease pathophysiology. This can open up the possibility of. manipulating the gut microbiome for improved symptom control and for the development of novel therapeutic approaches in schizophrenia and related psychotic disorders.

The mediating effect of allostatic load on the relationship between neighborhood perceptions and depression

Neighborhood perceptions is an important predictor of both allostatic load in the form of biological dysregulation and major depressive disorder. Furthermore, biological dysregulation is predictive of major depressive disorder. Yet to date, the use of biological dysregulation as one potential causal pathway linking neighborhood perceptions to depression has not been explored. This study examined the relationship between neighborhood perception, biological dysregulation in the form of allostatic load, and depression among individuals who participated in the three waves of the Midlife Development in the United States study (1996-2014). Two-to-one propensity score matching was employed prior the use of causal mediation analyses. Lower neighborhood perceptions at wave one were associated with increased allostatic load at wave two. Allostatic load at wave two is associated with depression at wave three. The mediation analysis shows that 6.0% of the relationship between neighborhood perception and depression is mediated by biological dysregulation. These results can inform future prevention and treatment methods by supporting efforts to integrate individuals and community-level interventions to aid in addressing both the environmental conditions and biological factors associated with depression.

A history of childhood trauma and allostatic load in patients with psychotic disorders with respect to stress coping strategies

Elevated allostatic load (AL) index, which is a cumulative measure of biological dysregulations associated with stress exposure, has been demonstrated in patients with psychosis. However, it remains unknown whether a history of childhood trauma (CT) might contribute to elevated AL index in psychosis. Therefore, we aimed to investigate the association between AL index, a history of CT and coping styles in patients with psychotic disorders. Participants were 65 patients with schizophrenia-spectrum disorders and 56 healthy controls (HCs). The AL index was computed based on percentile distributions of 15 biomarkers in HCs. The AL index was significantly higher in patients with psychosis. A history of parental antipathy was associated with elevated AL index in both groups of participants. A history of any categories of CT and sexual abuse were associated with higher AL index only in patients with psychosis. Social diversion (seeking social interactions in case of stressful experiences) mediated the association between sexual abuse and the AL index in the group of patients. There was a significant direct effect of sexual abuse on the AL index (this specific CT was associated with higher AL index). However, indirect effect of sexual trauma on AL through social diversion was opposite to direct effect. Childhood adversities, especially sexual abuse and parental antipathy, might contribute to elevated AL index in patients with psychosis. The effect of sexual abuse on the AL index might be specific to psychosis. Engagement in social interactions in case of stressful situations might alleviate biological dysregulations associated with CT.

Choroid Plexus Enlargement and Allostatic Load in Schizophrenia

Although schizophrenia is a brain disorder, increasing evidence suggests that there may be body-wide involvement in this illness. However, direct evidence of brain structures involved in the presumed peripheral-central interaction in schizophrenia is still unclear. Seventy-nine previously treatment-naïve first-episode schizophrenia patients who were within 2-week antipsychotics initial stabilization, and 41 age- and sex-matched healthy controls were enrolled in the study. Group differences in subcortical brain regional structures measured by MRI and the subclinical cardiovascular, metabolic, immune, and neuroendocrine biomarkers as indexed by allostatic load, and their associations were explored. Compared with controls, patients with schizophrenia had significantly higher allostatic load (P = .001). Lateral ventricle (P < .001), choroid plexus (P < .001), and thalamus volumes (P < .001) were significantly larger, whereas amygdala volume (P = .001) was significantly smaller in patients. The choroid plexus alone was significantly correlated with higher allostatic load after age, sex, education level, and the total intracranial volume were taken into account (t = 3.60, P < .001). Allostatic load was also significantly correlated with PANSS positive (r = 0.28, P = .016) and negative (r = -0.31, P = .008) symptoms, but in opposite directions. The peripheral multisystemic and central nervous system abnormalities in schizophrenia may interact through the choroid plexus during the early stage of the illness. The choroid plexus might provide a sensitive structural biomarker to study the treatment and prevention of brain-periphery interaction abnormalities in schizophrenia.

Hypothalamic-pituitary-adrenal axis activation in a high-risk sample of children, adolescents and young adults in residential youth care - Associations with adverse childhood experiences and mental health problems

Adverse childhood experiences (ACEs) lead to devastating long-term health consequences that are associated with a dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis. Children and adolescents living in institutional care have an increased risk to experience ACEs, particularly linked to missing continuity of care, and a higher risk for consequences of ACEs such as mental disorders. In order to improve the overall quality of care, it is important to better understand the stress-physiology of this high-risk sample and to identify specific stressors linked to adverse outcomes. Therefore, we assessed ACEs due to missing continuity of care and their association with hair cortisol and DHEA levels in children, adolescents and young adults in institutional care. Results show that ACEs resulting from the family of origin, in detail maternal mental illness, and ACEs due to out-of-home placement, namely frequent change of caregivers, are associated with HPA axis over-activation. HPA axis activation is associated with enhanced mental health problems. These results point towards an association between continuity of care and the stress system of children and adolescents in this high-risk sample. Care concepts that focus on continuity of care might help to reduce these physiological alterations and devastating long-term consequences following ACEs.

Stress, Allostatic Load, and Psychosis: One Step Forward in Research But Where to Go Next?

Stress exposure leads to the activation of several biological mechanisms that have been termed allostasis. These processes enable adaptation to novel situations; however; their prolonged activation exerts systemic and detrimental effects called the allostatic load (AL). The AL concept represents one of useful paradigms to describe biological consequences of chronic stress that might lead to a number of disease outcomes. The AL index, which is a collective measure of cardiovascular, metabolic, neuroendocrine, and immune dysregulations associated with stress exposure, has been found to predict morbidity and mortality in non-clinical populations. Consequently, it has been proposed that the AL concept might be a useful framework to describe biological consequences of chronic stress exposure in patients with psychotic disorders. This perspective article is an overview of studies investigating the AL index and its clinical correlates in patients with psychotic disorders. These studies have consistently reported elevated AL index in patients at the early and chronic course of psychosis. In addition, the AL index has been associated with a higher severity of positive and depressive symptoms, working memory impairments, and lower general functioning. The article provides some critical appraisal of studies in this field and indicates several future directions for investigating the AL concept in psychosis.

The Role of Hippocampal Functional Connectivity on Multisystem Subclinical Abnormalities in Schizophrenia

OBJECTIVE

Schizophrenia is associated with excess medical mortality: patients have an average life expectancy one to two decades shorter than the general population. This study investigates the relationship between aberrant hippocampal resting-state functional connectivity in schizophrenia and cumulative subclinical effects of chronic stress on metabolic, cardiovascular, and immune function using the allostatic load index.

METHODS

Cumulative stress was estimated using allostatic load total score (range, 0-13) in 46 patients with schizophrenia and 31 controls matched for age and sex (patients: age = 36.1 [13.7] years, sex = 32/14 male/female; controls: age = 35.5 [14.1], sex = 21/10 male/female). Hippocampal functional connectivity was assessed using resting-state functional magnetic resonance imaging; hippocampal structural connectivity was assessed using fornix fractional anisotropy. Linear regression analysis was used a) to test the hypothesis that aberrant hippocampal resting-state functional connectivity in schizophrenia (identified in analysis of schizophrenia - control differences) is associated with elevated allostatic load scores in patients and b) to determine the association between fornix fractional anisotropy with allostatic load.

RESULTS

In patients, higher allostatic load was significantly associated with reduced resting functional connectivity between the left hippocampus and right cingulate cortex and left precentral gyrus, but higher connectivity between the right hippocampus and left cerebellum lobe VI (corrected p values <. 05). In controls, reductions in both hippocampal structural connectivity and hippocampal-cingulate functional connectivity were associated with higher allostatic load scores.

CONCLUSIONS

These findings support basic neuroscience evidence that cumulative stress and hippocampal function are closely connected and suggest that abnormal hippocampal functional communication in schizophrenia may be related to elevated multisystem subclinical medical issues in patients as indexed by allostatic load.

Recovery from daily-life stressors in early and chronic psychosis

Initial affective and psychotic reactivity to daily stressors is altered in psychosis, and most notably in early psychosis. In addition to altered initial stress reactivity, results from studies using Experience Sampling Methodology (ESM) and psychophysiological measures indicate that impaired recovery from mild stressors may also be a risk factor for mental illness. The current ESM study investigated affective recovery from daily stressors in chronic psychosis patients (CP; n = 162), individuals at early stages of psychosis (EP; n = 127), and healthy volunteers (HV; n = 220) assessing fluctuations in negative affect (NA), tension, and suspiciousness ten times a day on six consecutive days. Recovery was operationalized for all three variables as the return to baseline (i.e., level at t_-1) following the first stressful event of a day (i.e., t₀). The EP group showed a delayed recovery of NA (t₁-t₃: B = 0.185; p = .007 and B = 0.228; p = .002) and suspiciousness (t₁: B = 0.223; p = .010 and B = 0.291; p = .002) compared to HV and CP, respectively. Delayed recovery was detected for tension as well (t₁-t₂: EP > HV: B = 0.242; p = .040 and EP > CP: B = 0.284; p = .023), but contrary to both other momentary states, this effect disappeared when controlling for subsequent stressful events. There were no significant differences in recovery between HV and CP. These results suggest that in EP, stressful daily events have longer-lasting effects on overall negative affect and subclinical psychotic-like experiences. Future studies should incorporate physiological and endocrine measures in order to integrate recovery patterns of the different stress systems.

Schizophrenia Mortality: Barriers to Progress

Individuals with schizophrenia die, on average, 20 years before their peers, with 'natural causes' accounting for 80% of premature deaths. The aim of this narrative review is to address this phenomenon from the perspective of known factors that contribute to long life. The relevant literature from the last decade was searched in PubMed and Google Scholar databases. Four factors have been shown to be common to centarians, people who live to be a hundred: genes, life style behaviors that favor a healthy heart, social support, and a subjective purpose in life. The latter three factors are potentially modifiable but, in the context of schizophrenia, there are barriers to change, namely poverty, illness symptoms, stress, stigma, and side effects of antipsychotic medication. Barriers to change need to be addressed before substantial progress can be made in increasing the health and mortality risk of people with schizophrenia.

Allostatic load index and its clinical correlates at various stages of psychosis

Accumulating evidence indicates systemic biological dysregulations in patients with psychosis that have been conceptualized as the "allostatic load" (AL) index. We aimed to investigate the AL index in 37 subjects at familial high risk of psychosis (FHRP), 42 first-episode psychosis (FEP) patients, 25 acutely relapsed schizophrenia (SCZ-AR) patients and 42 healthy controls (HCs), taking into account psychopathology and cognitive impairment. The AL index was calculated based on 15 biomarkers (cardiovascular markers, anthropometric measures, inflammatory markers, glucose homeostasis parameters, lipids and steroids). Cognition was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The AL index was significantly higher in patients with psychosis and FHR-P individuals compared to HCs. Patients with FEP and FHR-P individuals had similar AL index. Moreover, the AL index was significantly higher in SCZ-AR patients compared to other groups of participants. Higher AL index was associated with more severe general psychopathology and depressive symptoms, lower scores of attention (total score, digit span and digit coding tasks) and semantic fluency, as well as worse general functioning in patients with psychosis. There was a significant negative correlation between the AL index and the scores of attention (total score and digit coding task) in FHR-P individuals. No significant correlations between the AL index and cognition were found in HCs. Our results indicate that biological dysregulations, captured by the AL index, appear already in FHR-P individuals and progress with psychotic exacerbations. Elevated AL index might contribute to cognitive impairments in FHR-P individuals and patients with psychosis.

Evaluation of Nutritional Status and Allostatic Load in Adult Patients With Type 2 Diabetes

OBJECTIVE

Diabetes is a chronic disease, affected by nutritional status, and characterized by dysregulations in several systems. Allostatic load is an index that evaluates the dysregulation of all physiological and metabolic systems. This study was conducted to determine the relationship between nutritional status and allostatic load in patients with type 2 diabetes mellitus (T2DM).

METHODS

The study sample consisted of 30 males and 73 females between 20 and 55 years of age. Individuals had T2DM for 7.9±6.17 (mean ± standard deviation) years. World Health Organization criteria cutoffs were used to calculate allostatic load scores. Twelve parameters were questioned and an allostatic load score between 0 and 12 was obtained; values above the cutoff levels were assigned a value of 1, and values in the normal range were assigned a value of 0.

RESULTS

Individuals with high allostatic load comprised a significant portion of the sample (79.6%) for both males and females (73.3% and 82.2%, respectively). Longer diabetes duration was associated with high allostatic load score (p<0.05). There was lower vegetable consumption and higher fruit consumption in the high-allostatic-load group compared with the low-allostatic-load group (p<0.05). However, fruit consumption was still lower than recommended levels in both groups.

CONCLUSIONS

A significant number of individuals had high allostatic load scores in our study. A healthy diet plan in line with the recommendations may help to decrease the allostatic load scores by reducing body weight, waist/hip ratio, blood pressure and fasting blood glucose, and may prevent the negative effects of stress on metabolic processes in the long-term malnutrition in T2DM.

Appetite regulating hormones in first-episode psychosis: A systematic review and meta-analysis

We aimed to perform a systematic review and meta-analysis of appetite regulating hormones in patients with first-episode psychosis (FEP). Meta-analyses were conducted using random-effects models with Hedges' g as the effect size estimate. We identified 31 eligible studies, investigating the levels of 7 appetite regulating hormones (adiponectin, insulin, leptin, ghrelin, orexin, resistin and visfatin) in 1792 FEP patients and 1364 controls. The insulin levels in FEP patients were higher than in controls (g = 0.34, 95%CI: 0.19 - 0.49, p < 0.001), even considering only antipsychotic-naïve patients (g = 0.39, 95%CI: 0.12 - 0.66, p = 0.005). The severity of negative symptoms was positively associated with the effect size estimates (β = 0.08, 95%CI: 0.01 - 0.16, p = 0.030). Moreover, we found lower levels of leptin in antipsychotic-naïve FEP patients (g = -0.62, 95%CI: -1.11 - 0.12, p = 0.015). Impaired appetite regulation, in terms of elevated insulin levels and decreased leptin levels, occurs in early psychosis, before antipsychotic treatment. Hyperinsulinemia might be related to negative symptoms.

Hair cortisol, allostatic load, and depressive symptoms in Australian Aboriginal and Torres Strait Islander people

Chronic stress and adversity are associated with poor mental health and are thought to contribute to the existing mental health gap between Aboriginal and Torres Strait Islander people and other Australians. Hair cortisol and allostatic load (AL) are indices of sustained stress and may be mediators of the effects of stress on health. The aim of this study was to examine the relationship between hair cortisol, AL, and depressive symptoms. This cross-sectional study comprised 329 Aboriginal and Torres Strait Islander adolescents and adults recruited at two health screening programs operating in three communities in north Queensland. We measured hair cortisol and calculated an AL index from 10 biomarkers. We assessed depressive symptoms with a version of the Patient Health Questionnaire-9 adapted for Aboriginal and Torres Strait Islander people (aPHQ-9). We found differences in cortisol and AL between the screening programs and communities, which were not explained by depressive symptoms. Overall aPHQ-9 scores were unrelated to hair cortisol (p = .25 and p = .94) and AL (p = .30 and p = .88) when age, gender and smoking were taken into account. However, anhedonia (p = .007) and insomnia (p = .006) sub-scores were each significantly associated with AL in one study site. Our present data did not demonstrate overall associations of stress biomarkers and multisystem dysregulation with depressive symptoms, which suggests that the relationship between cumulative stress and depression may be better explained by other factors in this population. The specific association between anhedonia and insomnia with AL indicates that chronic multisystem dysregulation plays a role in these features of depression in this population. Lay summary Our study investigated the relationship between symptoms of depression and two biological pathways thought to mediate depression risk - the stress hormone cortisol and allostatic load (AL) - in an Australian Aboriginal and Torres Strait Islander population. Overall, cortisol and AL were unrelated to depression. However, AL was selectively associated with anhedonia (lack of motivation or drive) and sleep disturbances. These results suggest that metabolic dysregulation measured as AL may be relevant to the depression risk in this population.

Elevated allostatic load in individuals presenting at psychiatric emergency services

OBJECTIVE

Individuals requiring psychiatric emergency services are often highly distressed and intoxicated. To provide an objective and comprehensive measure of their stress-related physiological dysregulations, we indexed allostatic load with 14 biomarkers collected within 24 h of patients' admission to the largest psychiatric hospital in the Canadian province of Quebec.

METHODS

This study (N = 278) combines data for emergency patients (n = 76; 65.8% women; M age = 44.97, SE = 1.6) and hospital workers who served as sex- and age-matched controls (n = 202; 70.8% women; M age = 40.10, SE = 0.83). Sex-specific allostatic load indices summarized neuroendocrine (cortisol), immune (tumor necrosis factor-α, interleukin-6, c-reactive protein), metabolic (insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, body mass index), and cardiovascular (heart rate, systolic and diastolic blood pressure) functioning. Well-validated questionnaires assessed substance (ab)use.

RESULTS

Individuals presenting at psychiatric emergency showed elevated allostatic load, drug abuse, and tobacco use compared to controls. Elevated allostatic load in emergency patients was driven by elevated cortisol, interleukin-6, systolic blood pressure, and heart rate; however, allostatic load was not explained by substance (ab)use or demographic variables. Sub-group analyses revealed that emergency patients primarily diagnosed with bipolar, depressive, or anxiety disorders showed higher allostatic load than those diagnosed with personality disorder(s).

CONCLUSIONS

This study demonstrates that individuals presenting at psychiatric emergency services show physiological dysregulations associated with chronic stress. Future research should explore the clinical utility of allostatic load in predicting comorbidities among psychiatric patients.

Elevated allostatic load early in the course of schizophrenia

Stress plays a significant role in schizophrenia from disease onset to exacerbation of psychotic symptoms. Allostatic load (AL) is a measure of cumulative stress to the organism. This study is an extension of our previous work on AL and its relationship to brain structures. Here, we further determined whether elevated AL is a function of illness chronicity, or if it is already present early in the course of schizophrenia. AL was compared in schizophrenia patients early in the illness (within 5 years of disease onset), patients with chronic schizophrenia (more than 5 years of illness), and two groups of healthy controls that were age-and sex-matched to the two patient groups. This work is presented with an expanded sample and includes about two-thirds of the participants who were previously reported. We found that patients with early psychosis had significantly elevated AL score compared with their age-matched controls (p = 0.005). Chronic course patients also had elevated AL compared with age-matched controls (p = 0.003). Immune and stress hormone AL subcomponents were nominally higher in early-stage patients compared with controls (p = 0.005 and 0.04, respectively). Greater AL was also associated with more severe positive psychotic symptoms in early-stage patients (r = 0.54, p = 0.01). Elevated levels of allostatic load are already present in the early years of the schizophrenia illness, particularly in patients with more severe psychotic symptoms. AL may be a useful evaluation for the need of early intervention on psychosomatic comorbidity.

Decreased use of active coping styles contributes to elevated allostatic load index in first-episode psychosis

Accumulating evidence indicates that stress plays an important role in the development of psychotic disorders. Recent studies have revealed that patients with first-episode psychosis (FEP) present systemic biological dysregulations related to stress-exposure in terms of elevated allostatic load (AL) index. However, the mechanisms underlying this observation remain unknown. Therefore, in this study we aimed to investigate the AL index with respect to stress coping strategies in 36 FEP patients and 31 matched controls. We found significantly higher AL index in FEP patients compared to controls after co-varying for potential confounding factors. Patients with FEP were less likely to use active and task-focused coping. Lower odds of using these coping styles, planning as well as positive reinterpretation and growth were related to higher AL index in FEP patients, but not in controls. Depressive symptoms were associated with lower likelihood of using task-focused coping as well as positive reinterpretation and growth. Additionally, depressive symptoms were related to higher AL index. Finally, depressive symptoms mediated the effects of task-focused coping as well as positive reinterpretation and growth on the AL index. Our results confirm systemic biological dysregulation indexed as AL in FEP patients. Lower odds of using active coping styles might contribute to higher AL index via the mediating effect of depressive symptoms in patients with FEP. Longitudinal studies are required to establish causal inferences between coping styles, depressive symptoms and the AL index in early psychosis.