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Wada M, Noda Y, Iwata Y, Tsugawa S, Yoshida K, Tani H, Hirano Y, Koike S, Sasabayashi D, Katayama H, Plitman E, Ohi K, Ueno F, Caravaggio F, Koizumi T, Gerretsen P, Suzuki T, Uchida H, Müller DJ, Mimura M, Remington G, Grace AA, Graff-Guerrero A, Nakajima S. Dopaminergic dysfunction and excitatory/inhibitory imbalance in treatment-resistant schizophrenia and novel neuromodulatory treatment. Mol Psychiatry 2022; 27:2950-2967. [PMID: 35444257 DOI: 10.1038/s41380-022-01572-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Antipsychotic drugs are the mainstay in the treatment of schizophrenia. However, one-third of patients do not show adequate improvement in positive symptoms with non-clozapine antipsychotics. Additionally, approximately half of them show poor response to clozapine, electroconvulsive therapy, or other augmentation strategies. However, the development of novel treatment for these conditions is difficult due to the complex and heterogenous pathophysiology of treatment-resistant schizophrenia (TRS). Therefore, this review provides key findings, potential treatments, and a roadmap for future research in this area. First, we review the neurobiological pathophysiology of TRS, particularly the dopaminergic, glutamatergic, and GABAergic pathways. Next, the limitations of existing and promising treatments are presented. Specifically, this article focuses on the therapeutic potential of neuromodulation, including electroconvulsive therapy, repetitive transcranial magnetic stimulation, transcranial direct current stimulation, and deep brain stimulation. Finally, we propose multivariate analyses that integrate various perspectives of the pathogenesis, such as dopaminergic dysfunction and excitatory/inhibitory imbalance, thereby elucidating the heterogeneity of TRS that could not be obtained by conventional statistics. These analyses can in turn lead to a precision medicine approach with closed-loop neuromodulation targeting the detected pathophysiology of TRS.
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Affiliation(s)
- Masataka Wada
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoshihiro Noda
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yusuke Iwata
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Sakiko Tsugawa
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Kazunari Yoshida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Azrieli Adult Neurodevelopmental Centre, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Hideaki Tani
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Yoji Hirano
- Department of Neuropsychiatry, Kyushu University, Fukuoka, Japan.,Neural Dynamics Laboratory, Research Service, VA Boston Healthcare System, and Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Shinsuke Koike
- Center for Evolutionary Cognitive Sciences, Graduate School of Art and Sciences, The University of Tokyo, Tokyo, Japan
| | - Daiki Sasabayashi
- Department of Neuropsychiatry, University of Toyama Graduate School of Medicine and Pharmaceutical Sciences, Toyama, Japan.,Research Center for Idling Brain Science, University of Toyama, Toyama, Japan
| | - Haruyuki Katayama
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Eric Plitman
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kazutaka Ohi
- Department of Psychiatry, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Fumihiko Ueno
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Fernando Caravaggio
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
| | - Teruki Koizumi
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan.,Department of Psychiatry, National Hospital Organization Shimofusa Psychiatric Medical Center, Chiba, Japan
| | - Philip Gerretsen
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Takefumi Suzuki
- Department of Neuropsychiatry, University of Yamanashi Faculty of Medicine, Yamanashi, Japan
| | - Hiroyuki Uchida
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Daniel J Müller
- Tanenbaum Centre for Pharmacogenetics, Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Masaru Mimura
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan
| | - Gary Remington
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ariel Graff-Guerrero
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.,Institute of Medical Science, University of Toronto, Toronto, ON, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Shinichiro Nakajima
- Department of Neuropsychiatry, Keio University, School of Medicine, Tokyo, Japan. .,Brain Health Imaging Centre, Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada.
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Bozzatello P, Bellino S, Rocca P. Predictive Factors of Treatment Resistance in First Episode of Psychosis: A Systematic Review. Front Psychiatry 2019; 10:67. [PMID: 30863323 PMCID: PMC6399388 DOI: 10.3389/fpsyt.2019.00067] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 01/29/2019] [Indexed: 01/21/2023] Open
Abstract
Background: Clinical and functional outcome improvement in psychotic disorders is a challenge for the investigators. Recent advances offered opportunities for ameliorating the course of the illness during its early stages and for identifying treatment-resistant patients. Patients who had not response to two different antipsychotics, administered at correct doses for a sufficient period, can be operationally considered treatment-resistant. Available evidence suggested that the response's trajectory to the antipsychotic treatment revealed that a small proportion of subjects are poor responders (8.2%), the majority of patients have a moderate response (76.4%), and only 15.4% can be considered rapid responders with the greatest magnitude of response. Patients with first episode of psychosis generally obtain a more favorable response profile. Nevertheless, in around 25% of these patients symptoms of psychosis persist with a worse long-term course of illness. Objectives: The aim of this review is to report current evidences on the main predictors of treatment non-response in patients at early stage of psychosis. Methods: We used a specific string that guaranteed a high sensitive search in pubmed. We included the following types of publications: randomized-controlled trials, observational studies, longitudinal studies, retrospective studies, case-control studies, open-label investigations, cohort studies, and reviews. Publications must concern predictors of treatment resistance in early psychosis. Results: Forty-seven records were included: 5 reviews, 3 meta-analyses, 22 longitudinal studies, 2 retrospective studies, 1 naturalistic study, 6 randomized controlled trials, 2 open-label studies, 2 case-control studies, 4 cohort studies, 2 retrospective studies. Several factors were identified as predictors of treatment resistance: lower premorbid functioning; lower level of education; negative symptoms from first psychotic episode; comorbid substance use; younger age at onset; lack of early response; non-adherence to treatment; and longer duration of untreated psychosis. The role of gender and marital status is still controversial. More evidences are needed about neurobiological, genetic, and neuroimaging factors. Conclusions: The identification of specific predictive factors of treatment resistance in patients with first episode of psychosis ameliorates the quality of clinical management of these patients in the critical early phase of schizophrenia.
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Affiliation(s)
| | - Silvio Bellino
- Department of Neuroscience, University of Turin, Turin, Italy
| | - Paola Rocca
- Department of Neuroscience, University of Turin, Turin, Italy
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Kim E, Howes OD, Veronese M, Beck K, Seo S, Park JW, Lee JS, Lee YS, Kwon JS. Presynaptic Dopamine Capacity in Patients with Treatment-Resistant Schizophrenia Taking Clozapine: An [ 18F]DOPA PET Study. Neuropsychopharmacology 2017; 42:941-950. [PMID: 27857125 PMCID: PMC5312074 DOI: 10.1038/npp.2016.258] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Revised: 11/09/2016] [Accepted: 11/11/2016] [Indexed: 01/20/2023]
Abstract
Some patients with schizophrenia show poor response to first-line antipsychotic treatments and this is termed treatment-resistant schizophrenia. The differential response to first-line antipsychotic drugs may reflect a different underlying neurobiology. Indeed, a previous study found dopamine synthesis capacity was significantly lower in patients with treatment-resistant schizophrenia. However, in this study, the treatment-resistant patients were highly symptomatic, whereas the responsive patients showed no or minimal symptoms. The study could not distinguish whether this was a trait effect or reflected the difference in symptom levels. Thus, we aimed to test whether dopaminergic function is altered in patients with a history of treatment resistance to first-line drugs relative to treatment responders when both groups are matched for symptom severity levels by recruiting treatment-resistant patients currently showed low symptom severity with the clozapine treatment. Healthy controls (n=12), patients treated with clozapine (n=12) who had not responded to first-line antipsychotics, and patients who had responded to first-line antipsychotics (n=12) were recruited. Participants were matched for age and sex and symptomatic severity level in patient groups. Participants' dopamine synthesis capacity was measured by using [18F]DOPA PET. We found that patients treated with clozapine show lower dopamine synthesis capacity than patients who have responded to first-line treatment (Cohen's d=0.9191 (whole striatum), 0.7781 (associative striatum), 1.0344 (limbic striatum), and 1.0189 (sensorimotor striatum) in line with the hypothesis that the dopaminergic function is linked to treatment response. This suggests that a different neurobiology may underlie treatment-resistant schizophrenia and that dopamine synthesis capacity may be a useful biomarker to predict treatment responsiveness.
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Affiliation(s)
- Euitae Kim
- Department of Neuropsychiatry, Seoul National University Bundang Hospital, Gyeonggi-do, Korea
| | - Oliver D Howes
- Psychiatric Imaging, Medical Research Council Clinical Sciences Centre, Imperial College London, Hammersmith Hospital Campus, London, UK,Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mattia Veronese
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Katherine Beck
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Seongho Seo
- Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Korea,Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Woo Park
- Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Sung Lee
- Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Korea,Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yun-Sang Lee
- Department of Nuclear Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jun Soo Kwon
- Department of Brain & Cognitive Sciences, College of Natural Sciences, Seoul National University, Seoul, Korea,Department of Psychiatry, Seoul National University College of Medicine, Seoul, Korea,Department of Psychiatry, Seoul National University College of Medicine and Department of Brain and Cognitive Sciences, College of Natural Sciences, Seoul National University, 28 Yeongon-dong, Chongno-gu, Seoul 110-744, Korea, Tel: +82 2 2072 2972, Fax: +82 2 747 9063, E-mail:
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Howes OD, Kapur S. A neurobiological hypothesis for the classification of schizophrenia: type A (hyperdopaminergic) and type B (normodopaminergic). Br J Psychiatry 2014; 205:1-3. [PMID: 24986384 DOI: 10.1192/bjp.bp.113.138578] [Citation(s) in RCA: 146] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
SummarySchizophrenia is usually classified based on clinical presentation. However, the conventional paranoid–disorganised–residual distinctions have had limited clinical utility. Here we draw on the evidence for differences in pathophysiology underlying treatment response to propose a subclassification based on neurobiology to guide diagnostic testing and treatment.
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Affiliation(s)
- Oliver D Howes
- Oliver D. Howes, BM, BCh, MA, MRCPsych, PhD, DM, Departments of Psychological Medicine and Psychosis Studies, Institute of Psychiatry, King's College London; Shitij Kapur, FRCPC, PhD, FMedSci, Institute of Psychiatry, King's College London, UK
| | - Shitij Kapur
- Oliver D. Howes, BM, BCh, MA, MRCPsych, PhD, DM, Departments of Psychological Medicine and Psychosis Studies, Institute of Psychiatry, King's College London; Shitij Kapur, FRCPC, PhD, FMedSci, Institute of Psychiatry, King's College London, UK
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