Oestrogens, prolactin, hypothalamic-pituitary-gonadal axis, and schizophrenic psychoses

Leveraging sex-genetic interactions to understand brain disorders: recent advances and current gaps

It is established that there are sex differences in terms of prevalence, age of onset, clinical manifestations, and response to treatment for a variety of brain disorders, including neurodevelopmental, psychiatric, and neurodegenerative disorders. Cohorts of increasing sample sizes with diverse data types collected, including genetic, transcriptomic and/or phenotypic data, are providing the building blocks to permit analytical designs to test for sex-biased genetic variant-trait associations, and for sex-biased transcriptional regulation. Such molecular assessments can contribute to our understanding of the manifested phenotypic differences between the sexes for brain disorders, offering the future possibility of delivering personalized therapy for females and males. With the intention of raising the profile of this field as a research priority, this review aims to shed light on the importance of investigating sex-genetic interactions for brain disorders, focusing on two areas: (i) variant-trait associations and (ii) transcriptomics (i.e. gene expression, transcript usage and regulation). We specifically discuss recent advances in the field, current gaps and provide considerations for future studies.

Comparing pregnancy and pregnancy outcome rates between adolescents with and without pre-existing mental disorders

BACKGROUND

There are limited population-based data on the role of mental disorders in adolescent pregnancy, despite the presence of mental disorders that may affect adolescents' desires and decisions to become pregnant.

OBJECTIVE

This study aimed to examine the relationship between specific types of mental disorders and pregnancy rates and outcome types among adolescents aged 13-19 years, using single-year age groups.

METHODS

We conducted a retrospective cohort study using data from the Merative™ MarketScan Research Databases. The study population consisted of females aged 13-19 years with continuous insurance enrollment for three consecutive calendar years between 2005 and 2015. Pregnancy incidence rates were calculated both overall and within the different categories of mental disorders. The presence of mental disorders, identified through diagnosis codes, was classified into 15 categories. Pregnancy and pregnancy outcome types were determined using diagnosis and procedure codes indicating the pregnancy status or outcome. To address potential over- or underestimations of mental disorder-specific pregnancy rates resulting from variations in age distribution across different mental disorder types, we applied age standardization using 2010 U.S. Census data. Finally, multivariable logistic regression models were used to examine the relationships between 15 specific types of mental disorders and pregnancy incidence rates, stratified by age.

RESULTS

The age-standardized pregnancy rate among adolescents diagnosed with at least one mental disorder was 15.4 per 1,000 person-years, compared to 8.5 per 1,000 person-years among adolescents without a mental disorder diagnosis. Compared to pregnant adolescents without a mental disorder diagnosis, those with a mental disorder diagnosis had a slightly but significantly higher abortion rate (26.7% vs 23.8%, P-value < 0.001). Multivariable logistic regression models showed that substance use-related disorders had the highest odds ratios (ORs) for pregnancy incidence, ranging from 2.4 [95% confidence interval (CI): 2.1-2.7] to 4.5 [95% CI:2.1-9.5] across different age groups. Overall, bipolar disorders (OR range: 1.6 [95% CI:1.4-1.9]- 1.8 [95% CI: 1.7-2.0]), depressive disorders (OR range: 1.4 [95% CI: 1.3-1.5]- 2.7 [95% CI: 2.3-3.1]), alcohol-related disorders (OR range: 1.2 [95% CI: 1.1-1.4]- 14.5 [95% CI: 1.2-178.6]), and attention-deficit/conduct/disruptive behavior disorders (OR range: 1.1 [95% CI: 1.0-1.1]- 1.8 [95% CI: 1.1-3.0]) were also significantly associated with adolescent pregnancy, compared to adolescents without diagnosed mental disorders of the same age.

CONCLUSION

This study emphasizes the elevated rates of pregnancy and pregnancy ending in abortion among adolescents diagnosed with mental disorders, and identifies the particular mental disorders associated with higher pregnancy rates.

Promoting good mental health over the menopause transition

The potential risk for mental health conditions over the menopause transition shapes women's expectations and informs putative physiological mechanisms regulating women's mental health. We review evidence from prospective studies reporting on associations between mental health conditions and the menopause transition. Major depressive disorder and the more prevalent subthreshold depressive symptoms are the most common conditions studied. We reviewed 12 prospective studies reporting depressive symptoms, major depressive disorder, or both over the menopause transition and found no compelling evidence for a universal increased risk for either condition. However, specific subgroups of participants, primarily defined by menopause-related risk factors (ie, vasomotor symptoms that are severe or disturb sleep, a long duration of the transition, or reproductive hormone dynamics) and psychosocial risk factors (eg, stressful life events), were vulnerable to depressive symptoms. The increased risk of major depressive disorder over the menopause transition appears predominantly in individuals with previous major depressive disorder. Greater focus on recognising risk factors in primary care is warranted. On the basis of scarce data, we found no compelling evidence that risk of anxiety, bipolar disorder, or psychosis is universally elevated over the menopause transition. Potential misattribution of psychological distress and psychiatric disorders to menopause could harm women by delaying accurate diagnosis and the initiation of effective psychotropic treatments, and by creating negative expectations for people approaching menopause. A paradigm shift is needed. We conclude with recommendations for the detection and treatment of depressive symptoms or major depressive disorder and strategies to promote good mental health over the menopause transition, while responsibly preparing and supporting those at risk.

Estrogen and psychosis - a review and future directions

The link between sex hormones and schizophrenia has been suspected for over a century; however, scientific evidence supporting the pharmacotherapeutic effects of exogenous estrogen has only started to emerge during the past three decades. Accumulating evidence from epidemiological and basic research suggests that estrogen has a protective effect in women vulnerable to schizophrenia. Such evidence has led multiple researchers to investigate the role of estrogen in schizophrenia and its use in treatment. This narrative review provides an overview of the effects of estrogen as well as summarizes the recent work regarding estrogen as a treatment for schizophrenia, particularly the use of new-generation selective estrogen receptor modulators.

The genetic architecture of the human hypothalamus and its involvement in neuropsychiatric behaviours and disorders

Despite its crucial role in the regulation of vital metabolic and neurological functions, the genetic architecture of the hypothalamus remains unknown. Here we conducted multivariate genome-wide association studies (GWAS) using hypothalamic imaging data from 32,956 individuals to uncover the genetic underpinnings of the hypothalamus and its involvement in neuropsychiatric traits. There were 23 significant loci associated with the whole hypothalamus and its subunits, with functional enrichment for genes involved in intracellular trafficking systems and metabolic processes of steroid-related compounds. The hypothalamus exhibited substantial genetic associations with limbic system structures and neuropsychiatric traits including chronotype, risky behaviour, cognition, satiety and sympathetic-parasympathetic activity. The strongest signal in the primary GWAS, the ADAMTS8 locus, was replicated in three independent datasets (N = 1,685-4,321) and was strengthened after meta-analysis. Exome-wide association analyses added evidence to the association for ADAMTS8, and Mendelian randomization showed lower ADAMTS8 expression with larger hypothalamic volumes. The current study advances our understanding of complex structure-function relationships of the hypothalamus and provides insights into the molecular mechanisms that underlie hypothalamic formation.

Blood concentrations of anterior pituitary hormones in drug-naïve people with first-episode psychosis: A systematic review and meta-analysis

INTRODUCTION

The role of anterior pituitary hormones - i.e., adrenocorticotropic hormone (ACTH), luteinizing and follicle stimulating hormones (LH and FSH), growth hormone (GH), prolactin (PRL), and thyroid-stimulating hormone (TSH) - in early schizophrenia and psychoses unclear. We thus performed a systematic review and meta-analysis on the blood concentrations of ACTH, LH and FSH, GH, PRL, and TSH in drug-naïve people with first-episode psychosis (FEP) as compared with healthy controls.

METHODS

We searched Embase, MEDLINE, and PsycInfo for articles indexed until September 2022. Data quality was appraised. Random-effects meta-analyses were carried out, generating pooled standardized mean differences (SMDs). Between-study heterogeneity was estimated using the I2 statistic. Sensitivity and meta-regression analyses were performed.

RESULTS

Twenty-six studies were included. Drug-naïve people with FEP, compared to healthy subjects, had higher blood concentrations of ACTH (k = 7; N = 548; SMD = 0.62; 95%CI: 0.29 to 0.94; p < 0.001; I2 = 60.9%) and PRL (k = 17; N = 1757; SMD = 0.85; 95%CI: 0.56 to 1.14; p < 0.001; I2 = 85.5%) as well as lower levels of TSH (k = 6; N = 677; SMD = -0.34; 95%CI: -0.54 to -0.14; p = 0.001; I2 = 29.1%). Meta-regressions did not show any moderating effect of age (p = 0.78), sex (p = 0.21), or symptom severity (p = 0.87) on PRL concentrations in drug-naïve FEP. Available data were not sufficient to perform meta-analyses on FSH, LH, and GH.

CONCLUSIONS

Drug-naïve people with FEP have altered ACTH, PRL, and TSH blood concentrations, supporting the hypothesis that an abnormal anterior pituitary hormone secretion may be involved in the onset of schizophrenia and psychoses. Further research is needed to elucidate the role of pituitary hormones in FEP.

The Direct and Long-Term Effects of Raloxifene as Adjunctive Treatment for Schizophrenia-Spectrum Disorders: A Double-Blind, Randomized Clinical Trial

BACKGROUND AND HYPOTHESIS

Several studies suggest that raloxifene, a selective estrogen receptor modulator, improves symptoms and cognition in post-menopausal women with Schizophrenia-Spectrum Disorders (SSD). We aimed to assess the effects of adjunctive raloxifene in women and men with SSD.

STUDY DESIGN

This parallel, randomized, double-blind, placebo-controlled trial included adult SSD patients across the Netherlands and Belgium. Participants were stratified by age, sex, and global functioning and randomly assigned 1:1 to 12-week add-on raloxifene or placebo. Primary outcomes were symptom severity at 6, 12, and 38 weeks and cognition at 12 and 38 weeks, as measured with the Positive and Negative Syndrome Scale and the Brief Assessment of Cognition in Schizophrenia, respectively. Intention-to-treat analyses were performed using linear mixed-effect models.

STUDY RESULTS

We assessed 261 patients for eligibility, of which 102 (28% female) were assigned to raloxifene (n = 52) or placebo (n = 48). Although we found no main effect of raloxifene, secondary sex-specific analysis showed that in women, raloxifene had beneficial effects on negative symptoms at week 6 (LSM -2.92; adjusted P = 0.020) and week 12 (LSM -3.12; adjusted P = 0.030), and on working memory at week 38 (LSM 0.73; adjusted P = 0.040), while having negative effects on working memory at week 38 in men (LSM -0.53; adjusted P = 0.026). The number of adverse events was similar between groups.

CONCLUSIONS

Our results do not support the use of raloxifene in patients with SSD in general, but suggest female-specific beneficial effects of raloxifene on negative symptoms and working memory. Our findings encourage further research on sex-specific pharmacotherapeutic treatment.

Evidence-Based Recommendations for the Pharmacological Treatment of Women with Schizophrenia Spectrum Disorders

PURPOSE OF REVIEW

Despite clear evidence that sex differences largely impact the efficacy and tolerability of antipsychotic medication, current treatment guidelines for schizophrenia spectrum disorders (SSD) do not differentiate between men and women. This review summarizes the available evidence on strategies that may improve pharmacotherapy for women and provides evidence-based recommendations to optimize treatment for women with schizophrenia.

RECENT FINDINGS

We systematically searched PubMed and Embase for peer-reviewed studies on three topics: (1) sex differences in dose-adjusted antipsychotic serum concentrations, (2) hormonal augmentation therapy with estrogen and estrogen-like compounds to improve symptom severity, and (3) strategies to reduce antipsychotic-induced hyperprolactinemia. Based on three database studies and one RCT, we found higher dose-adjusted concentrations in women compared to men for most antipsychotics. For quetiapine, higher concentrations were specifically found in older women. Based on two recent meta-analyses, both estrogen and raloxifene improved overall symptomatology. Most consistent findings were found for raloxifene augmentation in postmenopausal women. No studies evaluated the effects of estrogenic contraceptives on symptoms. Based on two meta-analyses and one RCT, adjunctive aripiprazole was the best-studied and safest strategy for lowering antipsychotic-induced hyperprolactinemia. Evidence-based recommendations for female-specific pharmacotherapy for SSD consist of (1) female-specific dosing for antipsychotics (guided by therapeutic drug monitoring), (2) hormonal replacement with raloxifene in postmenopausal women, and (3) aripiprazole addition as best evidenced option in case of antipsychotic-induced hyperprolactinemia. Combining these strategies could reduce side effects and improve outcome of women with SSD, which should be confirmed in future longitudinal RCTs.

Paliperidone long-acting injection in the treatment of an adolescent with schizophrenia with fluctuating mental symptoms during menstrual period: a case report

Background

The treatment of schizophrenia, a chronic disabling psychiatric disorder, mainly relies on antipsychotics to control the disease and improve clinical symptoms. Various medication options are available, and differences in treatment effects, even for the same medication, have been noted. Treatment efficacy is correlated with the patient's sex, age, and physical condition. When a drug fails to achieve the desired effect or the symptoms are unstable, the drug dose is often increased or a change in medication is advised according to the patient's situation.

Case presentation

We report the case of a 16 years-old girl with schizophrenia and apparent psychotic symptoms. According to the genetic testing results, the symptoms were effectively controlled, and she was discharged from the hospital with the prescription of paliperidone sustained-release tablets. During the follow-up, her symptoms fluctuated during menstrual period, causing her great distress. Furthermore, her compliance gradually declined during the following 2 years of treatment, and the medication was often discontinued. We changed the drug from an oral tablet to an injection preparation while maintaining the active ingredients of the drug. The patient's symptoms were significantly controlled, and no fluctuation of symptoms occurred during the menstrual cycle.

Conclusion

Long-acting antipsychotic injections can be administered to female adolescents with schizophrenia who experience fluctuating psychotic symptoms during menstruation. This technique can ensure both consistency of medication and improvement in clinical symptoms.

Prefrontal microglia deficiency during adolescence disrupts adult cognitive functions and synaptic structures: A follow-up study in female mice

The prefrontal cortex (PFC) provides executive top-down control of a variety of cognitive processes. A distinctive feature of the PFC is its protracted structural and functional maturation throughout adolescence to early adulthood, which is necessary for acquiring mature cognitive abilities. Using a mouse model of cell-specific, transient and local depletion of microglia, which is based on intracerebral injection of clodronate disodium salt (CDS) into the PFC of adolescent male mice, we recently demonstrated that microglia contribute to the functional and structural maturation of the PFC in males. Because microglia biology and cortical maturation are partly sexually dimorphic, the main objective of the present study was to examine whether microglia similarly regulate this maturational process in female mice as well. Here, we show that a single, bilateral intra-PFC injection of CDS in adolescent (6-week-old) female mice induces a local and transient depletion (70 to 80% decrease from controls) of prefrontal microglia during a restricted window of adolescence without affecting neuronal or astrocytic cell populations. This transient microglia deficiency was sufficient to disrupt PFC-associated cognitive functions and synaptic structures at adult age. Inducing transient prefrontal microglia depletion in adult female mice did not cause these deficits, demonstrating that the adult PFC, unlike the adolescent PFC, is resilient to transient microglia deficiency in terms of lasting cognitive and synaptic maladaptations. Together with our previous findings in males, the present findings suggest that microglia contribute to the maturation of the female PFC in a similar way as to the prefrontal maturation occurring in males.

Obesity as pleiotropic risk state for metabolic and mental health throughout life

Obesity, a highly prevalent disorder and central diagnosis of the metabolic syndrome, is linked to mental health by clinical observations and biological pathways. Patients with a diagnosis of obesity may show long-lasting increases in risk for receiving psychiatric co-diagnoses. Austrian national registry data of inpatient services from 1997 to 2014 were analyzed to detect associations between a hospital diagnosis of obesity (ICD-10: E66) and disorders grouped by level-3 ICD-10 codes. Data were stratified by age decades and associations between each pair of diagnoses were computed with the Cochran-Mantel-Haenszel method, providing odds ratios (OR) and p values corrected for multiple testing. Further, directions of the associations were assessed by calculating time-order-ratios. Receiving a diagnosis of obesity significantly increased the odds for a large spectrum of psychiatric disorders across all age groups, including depression, psychosis-spectrum, anxiety, eating and personality disorders (all p_corr < 0.01, all OR > 1.5). For all co-diagnoses except for psychosis-spectrum, obesity was significantly more often the diagnosis received first. Further, significant sex differences were found for most disorders, with women showing increased risk for all disorders except schizophrenia and nicotine addiction. In addition to the well-recognized role in promoting disorders related to the metabolic syndrome and severe cardiometabolic sequalae, obesity commonly precedes severe mental health disorders. Risk is most pronounced in young age groups and particularly increased in female patients. Consequently, thorough screening for mental health problems in patients with obesity is urgently called for to allow prevention and facilitate adequate treatment.

Systematic review of the association between adverse life events and the onset and relapse of postpartum psychosis

Postpartum psychosis is defined as a psychotic episode occurring within 4 to 6  weeks of childbirth. While there is robust evidence that adverse life events are associated with the onset and relapse of psychosis outside the postpartum period, the extent to which these contribute to postpartum psychosis is less clear. This systematic review examined whether adverse life events are associated with an increased likelihood of developing postpartum psychosis or subsequent relapse in women diagnosed with postpartum psychosis. The following databases were searched from inception to June 2021: MEDLINE, EMBASE, PsycInfo. Study level data were extracted including setting, number of participants, type of adverse event, and differences between groups. A modified version of the Newcastle-Ottawa Quality Assessments Scale was used to assess risk of bias. In total, 1933 records were identified, of which 17 met the inclusion criteria, comprising nine case-control studies and eight cohort studies. Most studies (16/17) examined the association between adverse life events and the onset of postpartum psychosis, with only in which the outcome was relapse of psychosis. Overall, there were 63 different measures of adversity examined (most of which were examined in a single study only) and 87 associations between these measures and postpartum psychosis tested across the studies. In terms of statistically significant associations with onset/relapse of postpartum psychosis, 15 (17%) were positive (i.e., the adverse event increased the risk of onset/relapse), 4 (5%) were negative, and 68 (78%) were not statistically significant. Our review highlights the diversity of risk factors examined in this field, with few attempts at replication, hence limiting the ability to conclude that any single risk factor is robustly associated with the onset of postpartum psychosis. Further large-scale studies, that attempt to replicate earlier studies, are urgently needed to determine whether adverse life events play a role in the onset and exacerbation of postpartum psychosis.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=260592], identifier [CRD42021260592].

Identification of adolescent patients with depression via assessment of the niacin skin flushing response

BACKGROUND

Depressive disorder (DD) affects approximately 20 % of adolescents worldwide, but it is underdiagnosed due to the lack of objective biomarkers. Niacin skin flushing response (NSFR) is an objective and noninvasive biomarker of adult depression; however, its effectiveness has not been assessed in adolescents.

METHODS

This study included 198 adolescents with 50 % healthy controls (HC). Linear mixed-effects model and multiple linear regression analyses were performed to assess differences in NSFR between the DD and HC groups. Logistic regression models based on NSFR were constructed, and the area under curve (AUC) was calculated to evaluate the performance of models. Spearman correlations were calculated to assess the relationships between NSFR and disease duration and hormone levels associated with puberty.

RESULTS

Adolescents with DD displayed significantly attenuated and delayed NSFR compared to HC. NSFR effectively distinguished DD patients from HC with AUC values of 0.719 (sensitivity = 0.844) and 0.721 (sensitivity = 0.829) determined in the discovery and validation sets, respectively. Within the DD group, the maximum degree of NSFR was negatively correlated with the disease duration (r = -0.28, p = 0.011), and the overall degree of NSFR was positively associated with prolactin (r = 0.29, p = 0.039) and thyroxine (r = 0.29, p = 0.027) levels.

LIMITATIONS

Future investigations will be necessary to confirm our results in an independent sample set.

CONCLUSIONS

This study provides the first evidence of the utility of NSFR as an objective auxiliary diagnostic biomarker for adolescent depression. It provides new clues to understand the pathophysiology of the disease, and helps promote precise diagnosis, treatment, and prognostic evaluation of adolescent depression.

The Involvement of Prolactin in Stress-Related Disorders

The most important and widely studied role of prolactin (PRL) is its modulation of stress responses during pregnancy and lactation. PRL acts as a neuropeptide to support physiological reproductive responses. The effects of PRL on the nervous system contribute to a wide range of changes in the female brain during pregnancy and the inhibition of the hypothalamic-pituitary axis. All these changes contribute to the behavioral and physiological adaptations of a young mother to enable reproductive success. PRL-driven brain adaptations are also crucial for regulating maternal emotionality and well-being. Hyperprolactinemia (elevated PRL levels) is a natural and beneficial phenomenon during pregnancy and lactation. However, in other situations, it is often associated with serious endocrine disorders, such as ovulation suppression, which results in a lack of offspring. This introductory example shows how complex this hormone is. In this review, we focus on the different roles of PRL in the body and emphasize the results obtained from animal models of neuropsychiatric disorders.

Women with Schizophrenia-Spectrum Disorders After Menopause: A Vulnerable Group for Relapse

BACKGROUND AND HYPOTHESIS

Throughout the life stages of women with schizophrenia-spectrum disorders (SSD), lower estrogen levels are associated with more severe disease course. At perimenopause in the mid-forties, estrogen levels decline to remain persistently low after menopause. This period is hypothesized to increase relapse risk and reduce antipsychotic effectiveness in preventing relapse.

STUDY DESIGN

The cohort of persons with schizophrenia/schizoaffective disorder was identified from Finnish nationwide registers (N = 61 889) and stratified by sex and age <45 vs. ≥45 years. Hospitalizations for psychosis were defined per 5-year age group during the follow-up 1996-2017. Risk of psychosis hospitalization (Adjusted Hazard Ratio, aHR) was assessed using within-individual design, by comparing antipsychotic monotherapy use to nonuse periods in the same individuals for seven dose categories in defined daily doses (DDDs/day).

RESULTS

Starting at age 45-50, women were consistently more often hospitalized for psychosis than their male peers. Women ≥45 had significantly higher aHRs than women <45 at antipsychotic monotherapy >0.6 DDDs/day, and than men at >1.1 DDDs/day. This female-specific age-dependent decrease in effectiveness was present for clozapine doses >0.6 DDDs/day, olanzapine doses >1.4 DDDs/day, and for specific doses of quetiapine (0.9-1.1 DDDs/day) and risperidone (0.6-0.9 DDDs/day).

CONCLUSIONS

While younger women have a lower risk of relapse and generally need a lower antipsychotic dose to prevent rehospitalization than men, antipsychotic effectiveness declines in women after the age of 45. Starting in mid-forties, older women with SSD should be regarded as a vulnerable group that deserve special attention.

The Effect of Menopause on Antipsychotic Response

Background: It has been hypothesized that, whenever estrogen levels decline, psychosis symptoms in women increase. At menopause, this can happen in two main ways: (a) the loss of estrogen (mainly estradiol) can directly affect central neurotransmission, leading to increase in schizophrenia-related symptoms, and (b) the loss of estrogen can decrease the synthesis of enzymes that metabolize antipsychotic drugs, thus weakening their efficacy. Aims and Methods: The aim of this narrative review was to investigate the second possibility by searching PubMed and ClinicalTrials.gov for studies over the last two decades that investigated the metabolism of antipsychotics and their efficacy before and after menopause in women or that studied systemic and local estrogen level effects on the pharmacokinetics and pharmacodynamics of individual antipsychotic drugs. Results: The evidence suggests that symptom level in women with schizophrenia rises after menopause for many reasons beyond hormones but, importantly, there is an estrogen-dependent loss of efficacy related to antipsychotic treatment. Conclusion: Effective clinical intervention is challenging; nevertheless, several promising routes forward are suggested.

Microglia involvement in sex-dependent behaviors and schizophrenia occurrence in offspring with maternal dexamethasone exposure

Fetal microglia that are particularly sensitive cells to the changes in utero environment might be involved in the sex-biased onset and vulnerability to psychiatric disorders. To address this issue, we administered a 50 µg/kg dexamethasone (DEX) to dams subcutaneously from gestational days 16 to 18 and a series of behavioral assessments were performed in the offspring. Prenatal exposure to dexamethasone (PN-DEX) induced schizophrenia (SCZ)-relevant behaviors in male mice and depressive-like behavior in female mice. SCZ-relevant behavioral patterns occurred in 10-week-old (10 W) male mice but not in 4-week-old (4 W) male mice. Microglia in the medial prefrontal cortex (mPFC) and the striatum (STR) of 10 W males prenatally treated with dexamethasone (10 W PN-DEX-M) showed hyper-ramified morphology and dramatically reduced spine density in mPFC. Immunofluorescence studies indicated that microglia in the mPFC of the 10 W PN-DEX-M group interacted with pre-synaptic Bassoon and post-synaptic density 95 (PSD95) puncta. PN-DEX-M also showed significantly changed dopamine system proteins. However, a testosterone surge during adolescence was not a trigger on SCZ-relevant behavior occurrence in 10 W PN-DEX-M. Furthermore, females prenatally treated with dexamethasone (PN-DEX-F) displayed depressive-like behavior, in addition to HPA-axis activation and inflammatory microglial phenotypes in their hippocampus (HPC). We propose that altered microglial function, such as increased synaptic pruning, may be involved in the occurrence of SCZ-relevant behavior in PN-DEX-M and sex-biased abnormal behavior in the PN-DEX model.

Modeling the interplay of age at onset and sex on cognition in Schizophrenia

Cognition remains one of the most critical features of the schizophrenia. A wide range of factors has been associated to neurocognition and, among these, sex and age of onset are two of the most consistently reported to influence the functional and cognitive outcome. This work aims to evaluate the effects of sex and age of onset and their interaction on cognition in 419 subjects with schizophrenia. Analyses of variance and analyses of covariance were performed to evaluate the effect of sex and age at onset on cognition. To model the possible interaction sex-onset on cognition, a separate slope regression analysis was performed. Analyses of variance showed significant differences between sexes for age and age at onset, both significantly higher among females, as well as for Executive Functions, with higher performance among males. When compared according to age at onset, late-onset patients performed better than both early- and intermediate-onset ones in Verbal Memory subtest, with a significant effect of length of illness. Moreover, early-onset patients showed a significantly lower IQ compared to both intermediate and late-onset ones, with no significant effect of length of illness. Finally, the separate slope regression revealed a significant interaction between sex and age at onset, with early-onset being associated to a worse global cognition only among male patients. Our finding of a significant sex-onset interaction effect on neurocognition sheds new light on the complex issue of cognitive heterogeneity in schizophrenia. Our data may help towards the development of personalized programs for preventive and rehabilitative purposes.

Sex differences in prevalence and clinical correlates of insomnia in Chinese patients with chronic schizophrenia

OBJECTIVE

It is generally recognized that there are sex differences in many aspects of schizophrenia. The main purpose of this study was to investigate the sex differences in the prevalence and clinical correlates of insomnia in patients with chronic schizophrenia.

METHODS

A total of 957 patients who met the DSM-IV diagnostic criteria for schizophrenia were recruited in this cross-sectional study (male/female = 630/327). Demographic, clinical, and insomnia data were collected using self-reported questionnaires. Fasting blood samples were collected to evaluate the status of blood lipids. Psychopathological symptoms were evaluated using the Positive and Negative Syndrome Scale (PANSS).

RESULTS

The prevalence rate of insomnia in female patients with schizophrenia was significantly higher than that in male patients (17.3% for males and 26.3% for females; χ² = 10.74, p = 0.001). Regression analysis showed that in male patients, insomnia was independently associated with severe PANSS positive symptoms, severe PANSS depressive factor, and high levels of low-density lipoprotein levels, while in female patients, insomnia was associated with low education level, high PANSS depressive factor, and high levels of apolipoprotein B levels.

CONCLUSION

This study illustrates that insomnia is more frequent in female than male schizophrenia patients, and that there are differences in the clinical correlates of insomnia by sex, suggesting that sex differences should be considered in prevention and treatment strategies for coexisting insomnia in schizophrenia patients.

Brain anomalies in early psychosis: From secondary to primary psychosis

Brain anomalies are frequently found in early psychoses. Although they may remain undetected for many years, their interpretation is critical for differential diagnosis. In secondary psychoses, their identification may allow specific management. They may also shed light on various pathophysiological aspects of primary psychoses. Here we reviewed cases of secondary psychoses associated with brain anomalies, reported over a 20-year period in adolescents and young adults aged 13-30 years old. We considered age at first psychotic symptoms, relevant medical history, the nature of psychiatric symptoms, clinical red flags, the nature of the brain anomaly reported, and the underlying disease. We discuss the relevance of each brain area in light of normal brain function, recent case-control studies, and postulated pathophysiology. We show that anomalies in all regions, whether diffuse, multifocal, or highly localized, may lead to psychosis, without necessarily being associated with non-psychiatric symptoms. This underlines the interest of neuroimaging in the initial workup, and supports the hypothesis of psychosis as a global network dysfunction that involves many different regions.

The Influence of Oxytocin and Prolactin During a First Episode of Psychosis: The Implication of Sex Differences, Clinical Features, and Cognitive Performance

BACKGROUND

Approximately 3% of the population suffers a first episode of psychosis (FEP), and a high percentage of these patients subsequently relapse. Because the clinical course following a FEP is hard to predict, it is of interest to identify cognitive and biological markers that will help improve the diagnosis, treatment, and outcome of such events and to define new therapeutic targets. Here we analyzed the plasma oxytocin and prolactin levels during an FEP, assessing their correlation with clinical and cognitive features.

METHODS

The oxytocin and prolactin in plasma was measured in 120 FEP patients and 106 healthy controls, all of whom were subjected to a clinical and neuropsychological assessment. Most patients were under antipsychotics. Statistical analyses aimed to identify factors associated with the FEP and to search for associations between the variables. This study is preliminary and exploratory because the P-values were not corrected for multiple comparisons.

RESULTS

FEP patients had less oxytocin, more prolactin, and a poor premorbid IQ, and they performed worse in sustained attention. Male patients with higher prolactin levels experienced more severe psychotic symptoms and required higher doses of antipsychotics. Low oxytocin was associated with poor sustained attention in women, whereas low oxytocin and high prolactin in men correlated with better performance in sustained attention.

CONCLUSION

Low oxytocin, high prolactin, and poor premorbid IQ and sustained attention are factors associated with an FEP, representing potential therapeutic targets in these patients. These biological factors and cognitive domains might play an important role during a FEP, which could help us to develop new strategies that improve the outcomes of this disorder and that should perhaps be gender specific.

A population-based follow-up study shows high psychosis risk in women with PCOS

Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting up to 18% of women. Besides metabolic and fertility aspects, attention has lately been directed towards the detrimental effect of PCOS on psychological health. The objective of the study was to investigate whether women with PCOS are at higher risk for psychotic disorders. The study population derives from the Northern Finland Birth Cohort 1966 (N = 5889 women). The women with PCOS were identified by two simple questions on oligo-amenorrhea and hirsutism at age 31. Women reporting both symptoms were considered PCOS (N = 124) and asymptomatic women as controls (N = 2145). The diagnosis of psychosis was traced using multiple national registers up to the year 2016. Symptoms of psychopathology were identified using validated questionnaires at age 31. Women with PCOS showed an increased risk for any psychosis by age 50 (HR [95% CI] 2.99, [1.52-5.82]). Also, the risk for psychosis after age 31 was increased (HR 2.68 [1.21-5.92]). The results did not change after adjusting for parental history of psychosis, nor were they explained by body mass index or hyperandrogenism at adulthood. The scales of psychopathology differed between women with PCOS and non-PCOS controls showing more psychopathologies among the affected women. PCOS cases were found to be at a three-fold risk for psychosis, and they had increased psychopathological symptoms. PCOS should be taken into consideration when treating women in psychiatric care. More studies are required to further assess the relationship between PCOS and psychotic diseases.

Gender Differences in Dual Diagnoses Associated with Cannabis Use: A Review

Gender differences in psychiatric disorders and drug use are well known. Cannabis is the most widely used illegal drug among young people. In recent years, its use has been related to the development of psychiatric pathologies; however, few studies have incorporated the gender perspective as of yet. The present work analyses the literature to determine the existence of gender differences in the development of psychotic, depressive and anxious symptoms associated with cannabis use. First, we describe cannabis misuse and its consequences, paying special attention to adolescent subjects. Second, the main gender differences in psychiatric disorders, such as psychosis, depression, anxiety and cannabis use disorders, are enumerated. Subsequently, we discuss the studies that have evaluated gender differences in the association between cannabis use and the appearance of psychotic, depressive and anxious symptoms; moreover, we consider the possible explanations for the identified gender differences. In conclusion, the studies referred to in this review reveal the existence of gender differences in psychiatric symptoms associated with cannabis use, although the direction of such differences is not always clear. Future research is necessary to discern the causal relationship between cannabis use and the development of psychiatric symptoms, as well as the gender differences found.

Antipsychotic medication for women with schizophrenia spectrum disorders

There are significant differences between men and women in the efficacy and tolerability of antipsychotic drugs. Here, we provide a comprehensive overview of what is currently known about the pharmacokinetics and pharmacodynamics of antipsychotics in women with schizophrenia spectrum disorders (SSDs) and translate these insights into considerations for clinical practice. Slower drug absorption, metabolism and excretion in women all lead to higher plasma levels, which increase the risk for side-effects. Moreover, women reach higher dopamine receptor occupancy compared to men at similar serum levels, since oestrogens increase dopamine sensitivity. As current treatment guidelines are based on studies predominantly conducted in men, women are likely to be overmedicated by default. The risk of overmedicating generally increases when sex hormone levels are high (e.g. during ovulation and gestation), whereas higher doses may be required during low-hormonal phases (e.g. during menstruation and menopause). For premenopausal women, with the exceptions of quetiapine and lurasidone, doses of antipsychotics should be lower with largest adjustments required for olanzapine. Clinicians should be wary of side-effects that are particularly harmful in women, such as hyperprolactinaemia which can cause oestrogen deficiency and metabolic symptoms that may cause cardiovascular diseases. Given the protective effects of oestrogens on the course of SSD, oestrogen replacement therapy should be considered for postmenopausal patients, who are more vulnerable to side-effects and yet require higher dosages of most antipsychotics to reach similar efficacy. In conclusion, there is a need for tailored, female-specific prescription guidelines, which take into account adjustments required across different phases of life.

Sex difference in association between insomnia and cognitive impairment in patients with chronic schizophrenia

OBJECTIVE

Sex differences in schizophrenia have been noted across domains such as sleep and cognitive function； however, how they interact remains unclear. This study aimed to explore sex differences in the relationship between insomnia and cognitive function in patients with chronic schizophrenia.

METHODS

718 schizophrenia patients (480 males and 238 females) and 397 healthy controls were recruited. Insomnia was collected by a questionnaire. Insomnia severity index (ISI) was used to evaluate the severity of insomnia. The clinical symptoms and cognition were assessed with the Positive and Negative Syndrome Scale (PANSS) and the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), respectively.

RESULTS

Schizophrenia patients showed significantly lower scores compared to healthy controls on the RBANS total score and four indexes (all p < 0.05). Male patients had a lower rate of insomnia, higher scores on the RBANS visuospatial/constructional, language, and total score than female patients (all P < 0.05). Insomnia patients had lower RBANS immediate memory, language, and total scores than non-insomnia patients, and the results only appeared in female patients (all P < 0.05). In addition, there were significant negative correlations between ISI and RBANS language and delayed memory in male patients, while ISI was significantly negatively correlated with RBANS immediate memory in female patients (all P < 0.05).

CONCLUSION

Our findings suggest that there are sex differences in insomnia, cognitive performance, and their association in patients with chronic schizophrenia. These sex differences may have important potential clinical significance for the identification, evaluation, and treatment of insomnia in patients with chronic schizophrenia.

Classification of CHD7 Rare Variants in Chinese Congenital Hypogonadotropic Hypogonadism Patients and Analysis of Their Clinical Characteristics

Purpose:CHD7 rare variants can cause congenital hypogonadotropic hypogonadism (CHH) and CHARGE syndrome. We aimed to summarize the genotype and phenotype characteristics of CHH patients with CHD7 rare variants.

Methods: Rare sequencing variants (RSVs) were detected by Sanger sequencing in a series of 327 CHH patients and were interpreted and grouped according to the American College of Medical Genetics and Genomics (ACMG) guideline. Detailed phenotyping and genotype-phenotype correlation were analyzed.

Results: The RSV detection rate was 11.01% (36/327) in the CHH patients. We identified 30 RSVs and 19 of them were novel. Following ACMG criteria, three variants were pathogenic (P), 4 were likely pathogenic (LP), 3 were of uncertain significance with paradoxical evidence (US1), and 20 were of uncertain significance without enough evidence (US2). All patients (4/4, 100%) with P or LP variants manifested extragonadal symptoms.

Conclusion: Addition of 19 novel CHD7 variants expanded the spectrum of variants, and pathogenic or likely pathogenic RSVs were more likely to cause syndromic CHH. For CHH patients carrying CHD7 RSVs, detailed genotyping and phenotyping can facilitate clinical diagnosis and therapy.

[Unipolar depression: a gender-based comparative analysis]

OBJECTIVE

To compare socio-demographic and clinical characteristics in men and women with depression.

MATERIAL AND METHODS

We studied 388 patients with unipolar depression, 74 men and 314 women. The survey was carried out using the clinical-psychopathological method and psychometric scales for depression.

RESULTS AND CONCLUSION

Gender differences are identified for several parameters. Women are older, more often had comorbid somatic and organic disorders; men have personality disorders and chronic depression. The severity of depression in women was higher due to symptoms such as reported sadness, anxiety, reduced sleep and appetite, concentration difficulties, and suicidal thoughts. Apparent sadness did not significantly differ in men and women. Anhedonia was more pronounced in men.

Prolactin, metabolic and immune parameters in naïve subjects with a first episode of psychosis

BACKGROUND

Prolactin (Prl) is a pleiotropic hormone initially described for its regulation of lactation in mammals but later associated with metabolic and immune homeostasis, stress, inflammatory response and human behavior. Its regulation through dopamine receptors highlights its importance in psychiatry mostly because hyperprolactinemia is a common secondary side effect of dopamine antagonists. Despite its undeciphered patho-physiological mechanisms, hyperprolactinemia in naïve psychosis patients has been widely described. Its consequences might underlie the increased morbidity and early mortality found in naïve subjects as described in the general population where prolactin values have been correlated with inflammatory, immune and metabolic parameters.

METHODS

We aimed to evaluate the correlation between prolactin values and other biochemical parameters (C-reactive Protein-CrP, blood cell count, lipid and hepatic profile, fasting glucose) in a cohort of first episode psychosis naïve subjects (N = 491) stratified by sex. Regression analyses with confounders were performed to evaluate the association.

FINDINGS

Prl displayed significant correlations with C-Reactive Protein (CrP), Low-Density Lipoprotein (LDL), Aspartate Transaminase (AST) for females and High-Density Lipoprotein (HDL) and eosinophil count for males. However, and despite previous specific sex correlations, significant associations were described for CrP, HDL, LDL, AST and ALT without sex interaction and despite confounders such as age, Body Mass Index or smoking status.

CONCLUSIONS

Our results show a specific relation of Prl with immune and metabolic parameters describing a heterogeneous pattern. Our results suggest that prolactin might underlie the excess of morbidity and early mortality in naïve patients through a specific pathway.

Sex differences in antipsychotic efficacy and side effects in schizophrenia spectrum disorder: results from the BeSt InTro study

Current guidelines for patients with schizophrenia spectrum disease do not take sex differences into account, which may result in inappropriate sex-specific treatment. In the BeSt InTro study, a total of 144 patients (93 men and 51 women) with a schizophrenia spectrum diagnosis and ongoing psychosis were included and randomized to amisulpride, aripiprazole, or olanzapine in flexible dose. This trial is registered with ClinicalTrials.gov (NCT01446328). Primary outcomes were sex differences in dose, dose-corrected serum levels, efficacy, and tolerability. Dosing was higher for men than for women in the aripiprazole group (p = 0.025) and, at trend level, in the olanzapine group (p = 0.056). Dose-corrected serum levels were 71.9% higher in women than in men for amisulpride (p = 0.019) and 55.8% higher in women than in men for aripiprazole (p = 0.049). In the amisulpride group, men had a faster decrease in psychotic symptoms than women (p = 0.003). Moreover, amisulpride was more effective than the other medications in men but not in women. Prolactin levels were higher in women than in men, especially for amisulpride (p < 0.001). Also, women had higher BMI increase on amisulpride compared to the two other antipsychotics (p < 0.001). We conclude that clinicians should be aware of the risks of overdosing in women, especially for amisulpride and aripiprazole. Amisulpride is highly effective in men, but in women, amisulpride showed more severe side effects and may thus not be the drug of first choice. Our study shows that sex differences should be taken into account in future studies on antipsychotics. Future research is warranted to evaluate these preliminary results.

Sex Differences in Lifespan Trajectories and Variability of Human Sulcal and Gyral Morphology

Sex differences in the development and aging of human sulcal morphology have been understudied. We charted sex differences in trajectories and inter-individual variability of global sulcal depth, width, and length, pial surface area, exposed (hull) gyral surface area, unexposed sulcal surface area, cortical thickness, gyral span, and cortex volume across the lifespan in a longitudinal sample (700 scans, 194 participants 2 scans, 104 three scans, age range: 16-70 years) of neurotypical males and females. After adjusting for brain volume, females had thicker cortex and steeper thickness decline until age 40 years; trajectories converged thereafter. Across sexes, sulcal shortening was faster before age 40, while sulcal shallowing and widening were faster thereafter. Although hull area remained stable, sulcal surface area declined and was more strongly associated with sulcal shortening than with sulcal shallowing and widening. Males showed greater variability for cortex volume and lower variability for sulcal width. Our findings highlight the association between loss of sulcal area, notably through sulcal shortening, with cortex volume loss. Studying sex differences in lifespan trajectories may improve knowledge of individual differences in brain development and the pathophysiology of neuropsychiatric conditions.

Estrogens in schizophrenia: progress, current challenges and opportunities

PURPOSE OF REVIEW

Schizophrenia is a heterogeneous psychiatric disorder with a different, but not necessarily milder clinical presentation in women as compared to men. These sex differences have largely been attributed to the protective role of estrogens. This article reviews the current state of estrogen research in schizophrenia.

RECENT FINDINGS

Estrogens regulate important pathophysiological pathways in schizophrenia, including dopamine activity, mitochondrial function, and the stress system. Estrogen deficiency is common in both sexes and is associated with increases in psychotic symptoms. Hyperprolactinemia causes secondary estrogen deficiency and can be a reaction to stress, or secondary to prolactin-raising antipsychotics. Therefore, prolactin-sparing antipsychotics should be preferred especially in premenopausal women, who are more prone to hyperprolactinemia. Premenopausal women furthermore require lower doses of antipsychotics than men, since estrogens raise the availability and efficacy of antipsychotics.

SUMMARY

The past years have established the importance of estrogens in the pathophysiology of schizophrenia and have shown its relevance to clinical practice through its influence on antipsychotic drug efficacy. Future research should focus on the neurobiological and clinical effect of contraceptives in premenopausal women with schizophrenia. Furthermore, the potential of estrogen-like augmentation with raloxifene and phytoestrogens in schizophrenia should be established in the coming years.

Temporal variation in the incidence of treated psychotic disorders in young people

INTRODUCTION

The incidence of psychotic disorders varies between geographical areas, however less is known about whether it varies over time in the same region. Analyzing this temporal variation of incidence could improve the allocation of healthcare resources and our understanding of the aetiology of psychotic disorders. This study aimed to determine whether there was a change in the incidence of psychotic disorders over a six-year period.

METHODS

Young people aged 15 to 24 presenting with a first episode of psychosis (FEP) attending an early intervention service in Melbourne between 2011 and 2016 were included. The population at-risk was determined from the two corresponding census periods and analyses were adjusted for age, sex and migrant status.

RESULTS

A total of 1217 young people presented with a FEP over the six-year period and the crude incidence rate in 2011 was 102.4 per 100,000 population at-risk, compared to 125.4 in 2016. There was an increase in the incidence by 33% in 2015 (aIRR = 1.33, 95% CI 1.09-1.63) and 28% in 2016 (aIRR = 1.28, 95% CI 1.05-1.56). When examined according to diagnostic groups, there was an increase in the incidence of substance-induced psychotic disorders among females in 2015 (aIRR = 4.62, 95% CI 1.02-20.8).

DISCUSSION

This study shows significant temporal variations in the incidence of treated psychotic disorders. These findings demonstrate that early intervention services should continually monitor incidence case numbers and funding should be provided accordingly, to ensure the required intensive and comprehensive treatments can be sustained.

Gender differences in clinical presentation and illicit substance use during first episode psychosis: a natural language processing, electronic case register study

OBJECTIVE

To determine whether gender differences in symptom presentation at first episode psychosis (FEP) remain even when controlling for substance use, age and ethnicity, using natural language processing applied to electronic health records (EHRs).

DESIGN, SETTING AND PARTICIPANTS

Data were extracted from EHRs of 3350 people (62% male patients) who had presented to the South London and Maudsley NHS Trust with a FEP between 1 April 2007 and 31 March 2017. Logistic regression was used to examine gender differences in the presentation of positive, negative, depressive, mania and disorganisation symptoms.

EXPOSURES FOR OBSERVATIONAL STUDIES

Gender (male vs female).

MAIN OUTCOMES AND MEASURES

Presence of positive, negative, depressive, mania and disorganisation symptoms at initial clinical presentation.

RESULTS

Eight symptoms were significantly more prevalent in men (poverty of thought, negative symptoms, social withdrawal, poverty of speech, aggression, grandiosity, paranoia and agitation). Conversely, tearfulness, low energy, reduced appetite, low mood, pressured speech, mood instability, flight of ideas, guilt, mutism, insomnia, poor concentration, tangentiality and elation were more prevalent in women than men. Negative symptoms were more common among men (OR 1.85, 95% CI 1.33 to 2.62) and depressive and manic symptoms more common among women (OR 0.30, 95% CI 0.26 to 0.35). After adjustment for illicit substance use, the strength of associations between gender and negative, manic and depression symptoms increased, whereas gender differences in aggression, agitation, paranoia and grandiosity became insignificant.

CONCLUSIONS

There are clear gender differences in the clinical presentation of FEP. Our findings suggest that gender can have a substantial influence on the nature of clinical presentation in people with psychosis, and that this is only partly explained by exposure to illicit substance use.

Relation between self-perceived stress, psychopathological symptoms and the stress hormone prolactin in emerging psychosis

BACKGROUND

Psychosocial stress and the stress hormone prolactin are assumed to play an important role in the pathogenesis of schizophrenia and related psychoses, and have been frequently observed to be increased in antipsychotic-naïve patients with a clinical high risk for psychosis (CHR-P) or first episode of psychosis (FEP). The aim of this study was to further elucidate the relationships between self-perceived stress, psychopathological symptoms and prolactin levels in these patients.

METHODS

In this cross-sectional study, 45 healthy controls, 31 CHR-P patients and 87 FEP patients were recruited from two different study centers. Prolactin was measured under standardized conditions between 8 and 10 am. All patients were antipsychotic-naïve and not taking any prolactin influencing medication. Self-perceived stress during the last month was measured with the perceived stress scale (PSS-10) immediately before blood taking.

RESULTS

Both CHR-P and FEP patients showed significantly higher levels of self-perceived stress and prolactin than controls. Hyperprolactinemia (i.e. prolactin levels above the reference range) was observed in 26% of CHR-P and 45% of FEP patients. Self-perceived stress was significantly positively associated with affective symptoms, but not with other symptoms. There was no significant association between self-perceived stress and prolactin levels.

CONCLUSION

Our results confirm that CHR-P and FEP patients have higher stress levels than healthy controls and frequently have hyperprolactinemia, independent of antipsychotic medication. However, although it is well established that prolactin increases in response to stress, our results do not support the notion that increased prolactin levels in these patients are due to stress.

Clozapine tolerability in Treatment Resistant Schizophrenia: exploring the role of sex

Clozapine is the only evidence-based drug indicated for Treatment Resistant Schizophrenia but it is largely underprescribed, partially due to its life-threatening adverse effects (AEs). However, clozapine treatment is burdened by other common AEs as constipation, hypersalivation, postural hypotension, tachycardia and metabolic abnormalities. Few studies have investigated sex-related differences in clozapine's tolerability, reporting women to experience more frequently weight gain, hyperglycemia and constipation, while men hypertension and dyslipidemia. Based on these premises, we investigated clinical, psychopathological and metabolic sex-related differences among 147 treatment-resistant patients treated with clozapine, with a specific focus on non-life-threatening AEs. We observed significant higher prevalence of tachycardia in men, and of orthostatic hypotension and constipation in women. Concerning metabolic alterations, we observed significant lower levels of HDL-cholesterol and higher prevalence of hypertriglyceridemia among men, whereas females showed higher prevalence of abdominal obesity. Consistently with previous studies, our data confirm the presence of sex-related differences in clozapine tolerability, with a main effect of sex especially for tachycardia, postural hypotension and constipation. Although non-life-threatening, these common AEs significantly affect patients' quality of life, undermine compliance and cause treatment discontinuation. A better understanding of this topic could contribute to tailor therapeutic approaches, thus improving tolerability, compliance and clinical stability.

Sex-Specific Effect of Serum Lipids and Body Mass Index on Psychotic Symptoms, a Cross-Sectional Study of First-Episode Psychosis Patients

Background: Schizophrenia is a disorder with considerable heterogeneity in course and outcomes, which is in part related to the patients' sex. Studies report a link between serum lipids, body mass index (BMI), and therapeutic response. However, the role of sex in these relationships is poorly understood. In a cross-sectional sample of first-episode psychosis (FEP) patients, we investigated if the relationship between serum lipid levels (total cholesterol, HDL-C, LDL-C, and triglycerides), BMI, and symptoms differs between the sexes. Methods: We included 435 FEP patients (males: N = 283, 65%) from the ongoing Thematically Organized Psychosis (TOP) study. Data on clinical status, antipsychotics, lifestyle, serum lipid levels, and BMI were obtained. The Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS) were used to assess psychotic and depressive symptoms. General linear models were employed to examine the relationship between metabolic variables and symptomatology. Results: We observed a female-specific association between serum HDL-C levels and negative symptoms (B = -2.24, p = 0.03) and between triglycerides levels (B = 1.48, p = 0.04) and BMI (B = 0.27, p = 0.001) with depressive symptoms. When controlling for BMI, only the association between serum HDL-C levels and negative symptoms remained significant. Moreover, the HDL-C and BMI associations remained significant after controlling for demography, lifestyle, and illness-related factors. Conclusion: We found a relationship between metabolic factors and psychiatric symptoms in FEP patients that was sex-dependent.

The implications of hypothalamic abnormalities for schizophrenia

Until a few years ago, the hypothalamus was believed to play only a marginal role in schizophrenia pathophysiology. However, recent findings show that this rather small brain region involved in many pathways found disrupted-in schizophrenia. Gross anatomic abnormalities (volume changes of the third ventricle, the hypothalamus, and its individual nuclei) as well as alterations at the cellular level (circumscribed loss of neurons) can be observed. Further, increased or decreased expression of hypothalamic peptides such as oxytocin, vasopressin, several factors involved in the regulation of appetite and satiety, endogenous opiates, products of schizophrenia susceptibility genes as well as of enzymes involved in neurotransmitter and neuropeptide metabolism have been reported in schizophrenia and/or animal models of the disease. Remarkably, although profound disturbances of the hypothalamus-pituitary-adrenal axis, hypothalamus-pituitary-thyroid axis, and the hypothalamus-pituitary-gonadal axis are typical signs of schizophrenia, there is currently no evidence for alterations in the expression of hypothalamic-releasing and inhibiting factors that control these hormonal axes. Finally, the implications of hypothalamus for disease-related disturbances of the sleep-wakefulness cycle and neuroimmune dysfunctions in schizophrenia are outlined.

Safety and Efficacy of High-Dose Vitamin B6 as an Adjunctive Treatment for Antipsychotic-Induced Hyperprolactinemia in Male Patients With Treatment-Resistant Schizophrenia

This study aimed to investigate the safety and efficacy of high-dose vitamin B6 (vB6) as an adjunct treatment for antipsychotic-induced hyperprolactinemia (AIHP) in male patients with treatment-resistant schizophrenia (TRS). In this randomized double-blinded controlled study, patients were randomized (1:1) into a control group given aripiprazole (ARI; 10 mg/day; n = 100) or an intervention group given vB6 (300 mg/12 h for 16 weeks; n = 100). Prolactin levels, psychotic symptoms [Positive and Negative Syndrome Scale (PANSS)], cognitive function [MATRICS Consensus Cognitive Battery (MCCB)], liver function, kidney function, growth hormone level, micronutrient levels, blood lipids, and adverse secondary effects (ASEs)[Treatment Emergent Symptom Scale (TESS) and Barnes-Akathisia scale] were monitored. After a 16-week treatment period, the vB6 group showed a 68.1% reduction in serum prolactin levels (from 95.52 ± 6.30 μg/L to 30.43 ± 18.65 μg/L) while the ARI group showed only a 37.4% reduction (from 89.07 ± 3.59 μg/L to 55.78 ± 7.39 μg/L). During weeks 1-4, both treatments reduced prolactin similarly. Subsequently, the ARI effect plateaued, while the vB6 effect remained robust. The vB6 group showed better alleviation of psychotic symptoms and cognitive impairment. No serious ASEs were observed; ASEs were more frequent in the ARI group. AIHP reduction efficacy of vB6 was associated with baseline prolactin and triglyceride levels, total vB6 dosage, and education level. In conclusion, compared with the ARI group, TRS patients given vB6 showed better attenuation of AIHP, lower ASE scores, and greater improvements in clinical symptoms and cognitive impairments. These results support further consideration of vB6 as a putative treatment for AIHP. Trial Registration: ChiCTR1800014755.

The Role of Estrogen Receptors and Their Signaling across Psychiatric Disorders

Increasing evidence suggests estrogen and estrogen signaling pathway disturbances across psychiatric disorders. Estrogens are not only crucial in sexual maturation and reproduction but are also highly involved in a wide range of brain functions, such as cognition, memory, neurodevelopment, and neuroplasticity. To add more, the recent findings of its neuroprotective and anti-inflammatory effects have grown interested in investigating its potential therapeutic use to psychiatric disorders. In this review, we analyze the emerging literature on estrogen receptors and psychiatric disorders in cellular, preclinical, and clinical studies. Specifically, we discuss the contribution of estrogen receptor and estrogen signaling to cognition and neuroprotection via mediating multiple neural systems, such as dopaminergic, serotonergic, and glutamatergic systems. Then, we assess their disruptions and their potential implications for pathophysiologies in psychiatric disorders. Further, in this review, current treatment strategies involving estrogen and estrogen signaling are evaluated to suggest a future direction in identifying novel treatment strategies in psychiatric disorders.

Progression from being at-risk to psychosis: next steps

Over the past 20 years there has been a great deal of research into those considered to be at risk for developing psychosis. Much has been learned and studies have been encouraging. The aim of this paper is to offer an update of the current status of research on risk for psychosis, and what the next steps might be in examining the progression from CHR to psychosis. Advances have been made in accurate prediction, yet there are some methodological issues in ascertainment, diagnosis, the use of data-driven selection methods and lack of external validation. Although there have been several high-quality treatment trials the heterogeneity of this clinical high-risk population has to be addressed so that their treatment needs can be properly met. Recommendations for the future include more collaborative research programmes, and ensuring they are accessible and harmonized with respect to criteria and outcomes so that the field can continue to move forward with the development of large collaborative consortiums as well as increased funding for multisite projects.

Reduced Brd1 expression leads to reversible depression-like behaviors and gene-expression changes in female mice

The schizophrenia-associated gene, BRD1, encodes an epigenetic regulator in which chromatin interactome is enriched with genes implicated in mental health. Alterations in histone modifications and epigenetic regulation contribute to brain transcriptomic changes in affective disorders and preclinical data supports a role for BRD1 in psychopathology. However, the implication of BRD1 on affective pathology remains poorly understood. In this study, we assess affective behaviors and associated neurobiology in Brd1^+/- mice along with their responses to Fluoxetine and Imipramine. This involves behavioral, neurostructural, and neurochemical characterizations along with regional cerebral gene expression profiling combined with integrative functional genomic analyses. We report behavioral changes in female Brd1^+/- mice with translational value to depressive symptomatology that can be alleviated by the administration of antidepressant medications. Behavioral changes are accompanied by altered brain morphometry and imbalances in monoaminergic systems. In accordance, gene expression changes across brain tissues reveal altered neurotransmitter signaling and cluster in functional pathways associated with depression including 'Adrenergic-, GPCR-, cAMP-, and CREB/CREM-signaling'. Integrative gene expression analysis specifically links changes in amygdaloid intracellular signaling activity to the behavioral treatment response in Brd1^+/- mice. Collectively, our study highlights the importance of BRD1 as a modulator of affective pathology and adds to our understanding of the molecular mechanisms underlying affective disorders and their treatment response.

Neuroimmune Mechanisms and Sex/Gender-Dependent Effects in the Pathophysiology of Mental Disorders

Innate and adaptive immune mechanisms have emerged as critical regulators of CNS homeostasis and mental health. A plethora of immunologic factors have been reported to interact with emotion- and behavior-related neuronal circuits, modulating susceptibility and resilience to mental disorders. However, it remains unclear whether immune dysregulation is a cardinal causal factor or an outcome of the pathologies associated with mental disorders. Emerging variations in immune regulatory pathways based on sex differences provide an additional framework for discussion in these psychiatric disorders. In this review, we present the current literature pertaining to the effects that disrupted immune pathways have in mental disorder pathophysiology, including immune dysregulation in CNS and periphery, microglial activation, and disturbances of the blood-brain barrier. In addition, we present the suggested origins of such immune dysregulation and discuss the gender and sex influence of the neuroimmune substrates that contribute to mental disorders. The findings challenge the conventional view of these disorders and open the window to a diverse spectrum of innovative therapeutic targets that focus on the immune-specific pathophenotypes in neuronal circuits and behavior. SIGNIFICANCE STATEMENT: The involvement of gender-dependent inflammatory mechanisms on the development of mental pathologies is gaining momentum. This review addresses these novel factors and presents the accumulating evidence introducing microglia and proinflammatory elements as critical components and potential targets for the treatment of mental disorders.

Risk factors of hyperprolactinemia induced by risperidone and olanzapine and their correlations with plasma glucose and lipids

Background

Hyperprolactinemia is a common adverse reaction in patients with schizophrenia who take antipsychotic drugs; it often leads to treatment non-compliance in patients and has an adverse effect on their prognosis.

Aims

This study aimed to explore the risk factors of elevated prolactin (PRL) caused by risperidone (RIS) and olanzapine (OLZ) and the relationship between PRL and fasting plasma glucose and lipids.

Methods

Patients with schizophrenia were divided into two groups: 264 patients who were taking RIS and 175 patients who were taking OLZ. These two groups were further divided according to serum PRL levels: an elevated PRL group (>30 ng/mL) and a normal PRL group (PRL ≤30 ng/mL). The demographics, medication dosage, fasting plasma glucose, total cholesterol and triglycerides were compared in the two groups. Logistic regression analysis was performed to explore the risk factors of elevated PRL levels.

Results

Compared with the OLZ group, the RIS group had a greater number of patients with elevated PRL (155/264 vs 58/175). Either the RIS or the OLZ group, the proportion of elevated PRL was greater in female patients (RIS: χ²=6.76, p=0.009; OLZ: χ²=12.98, p<0.001) and with higher doses of the related drugs (RIS: U=-3.73, p<0.001; OLZ: U=-2.31, p=0.021). In patients taking RIS, the elevated PRL subgroup took the drug for a longer period (U=-2.76, p=0.006) and had lower triglyceride levels (U=2.76, p=0.006). In patients taking OLZ, the elevated PRL subgroup had lower fasting plasma glucose levels (U=2.29, p=0.022). Logistic regression analysis showed that gender, dose and fasting glucose levels were significantly associated with elevated PRL levels (RIS: p=0.001, OLZ: p<0.001; RIS: p<0.001; OLZ: p=0.003; RIS: p=0.020, OLZ: p=0.001, respectively).

Conclusion

Compared with OLZ, RIS had a greater effect on PRL in patients with schizophrenia, and in patients with schizophrenia taking RIS or OLZ, gender and dose were significantly correlated with the PRL value. Moreover, the plasma glucose level of the group with elevated PRL was lower than that of the group with normal PRL. The results also showed that high serum PRL may be associated with a favourable glucose metabolic profile in patients with schizophrenia taking RIS or OLZ. Further studies are warranted to confirm this association.

Trial registration number

NCT02640911.

Women Undergoing Hormonal Treatments for Infertility: A Systematic Review on Psychopathology and Newly Diagnosed Mood and Psychotic Disorders

BACKGROUND

The association between infertility treatments and mental disorders has been poorly addressed. This work aims to review current evidence on the psychopathological effects of hormonal treatments used for infertility on women and the occurrence of newly diagnosed mood and psychotic disorders.

METHODS

A systematic review was performed by searching PubMed and clinicaltrials.gov databases from inception until September 2019. Clinical trials on hormone treatments for infertility in patients with mood or psychotic disorders, as well as those evaluating the onset of symptoms, were included. Selected studies were published in English, Spanish, and Dutch language peer-reviewed journals. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Observational studies and case reports were excluded. Effect sizes for changes in depressive symptoms were calculated with Hedges'g and Cohen's d confidence intervals. A meta-analysis was not performed due to the heterogeneity of hormonal compounds in protocols.

RESULTS

From 1,281 retrieved records, nine trials were included; all of them were conducted in non-clinical populations. Four trials compared Gonadotropin-releasing hormone (GnRH) agonists and GnRH antagonists, showing a better mood profile for hormonal protocols including antagonists in one trial. Two trials compared protocols using GnRH agonists/antagonists versus natural cycle protocols (without gonadotropin stimulation), with a better mood profile (less depressive symptoms) in those protocols without gonadotropin stimulation. Other studies compared long and short protocols of GnRH agonists (no differences); two GnRH agonists, buserelin, and goserelin (no differences); and two patterns of clomiphene vs placebo administration (no differences). None of the selected studies investigated the risk of relapse in women with a previous diagnosis of depressive or psychotic disorders. When exploring pre-post changes in depressive symptoms, effect sizes suggested mild mood worsenings for most protocols (effect sizes ≤ -0.4), with the following pattern (worse to better): GnRH agonist > GnRH antagonist > no gonadotropin stimulation.

CONCLUSIONS

This is the first systematic review exploring the psychopathological effects of hormonal infertility treatments. Our study suggests that protocols without gonadotropin stimulation show a better mood profile when compared to those using GnRH antagonists or GnRH agonists. Future studies need to include patients with major mood and psychotic disorders.

Moderators and mediators of antipsychotic response in delusional disorder: Further steps are needed

Delusional disorder (DD) has been traditionally considered a relatively rare and treatment-resistant psychotic disorder. In the last decade, increasing attention has focused on therapeutic outcomes of individuals affected by this disorder. The aim of this paper is to provide a synthesis of the literature addressing two very important questions arising from DD research: (1) For which patients with DD do antipsychotic medications work best (the moderators of response); and (2) What variables best explain the relationship between such treatments and their effectiveness (the mediators of response). We searched PubMed and Google Scholar databases for English, German, French and Spanish language papers published since 2000. We also included a few classic earlier papers addressing this topic. Variables potentially moderating antipsychotic response in DD are gender, reproductive status, age, duration of illness, the presence of comorbidity (especially psychiatric comorbidity) and its treatment, brain structure, and genetics of neurochemical receptors and drug metabolizing enzymes. Antipsychotic and hormonal blood levels during treatment, as well as functional brain changes, are potential mediating variables. Some, but not all, patients with DD benefit from antipsychotic treatment. Understanding the circumstances under which treatment works best can serve to guide optimal management.

The longitudinal course of schizophrenia: testosterone and progression of the negative symptoms

Background: The longitudinal course of schizophrenia shows a high level of heterogeneity with testosterone as a possible factor in the variety of clinical outcomes.Aim: Evaluation of the course of schizophrenia in male patients over an eight-year period and of the possible testosterone effects on changes in clinical features.Subjects and methods: The initial study population consisted of 120 male schizophrenic patients (aged 18-40) hospitalized in the University Psychiatric Hospital Vrapce in 2009. Patients were classified into nonaggressive (control, n = 60) and aggressive (n = 60) groups. In 2017, we reassessed 85 patients (67,5%) from the initial sample. Symptoms of schizophrenia were determined using the Positive and Negative Syndrome Scale (PANSS) and compared with the total serum testosterone level taken at the inclusion in the study. The distribution of values for individual variables was determined using the Smirnov-Kolmogorov test; for all further analyses, the appropriate non-parametric test was used.Results: The control group showed a statistically significant negative correlation between testosterone and negative PANSS. The initial PANSS scores, compared to those at the follow-up, showed a statistically significant reduction in positive and general symptoms in all groups, with the greatest reduction in the control group.Conclusion: We found a reduction in positive and general symptoms of schizophrenia among all patients and no changes in negative symptoms. Inverse correlation between testosterone and negative symptoms was found only in the control group, but there was no testosterone influence on the progression of any PANSS subscales.

Estradiol reverses excitatory synapse loss in a cellular model of neuropsychiatric disorders

Loss of glutamatergic synapses is thought to be a key cellular pathology associated with neuropsychiatric disorders including schizophrenia (SCZ) and major depressive disorder (MDD). Genetic and cellular studies of SCZ and MDD using in vivo and in vitro systems have supported a key role for dysfunction of excitatory synapses in the pathophysiology of these disorders. Recent clinical studies have demonstrated that the estrogen, 17β-estradiol can ameliorate many of the symptoms experienced by patients. Yet, to date, our understanding of how 17β-estradiol exerted these beneficial effects is limited. In this study, we have tested the hypothesis that 17β-estradiol can restore dendritic spine number in a cellular model that recapitulates the loss of synapses associated with SCZ and MDD. Ectopic expression of wildtype, mutant or shRNA-mediated knockdown of Disrupted in Schizophrenia 1 (DISC1) reduced dendritic spine density in primary cortical neurons. Acute or chronic treatment with 17β-estradiol increased spine density to control levels in neurons with altered DISC1 levels. In addition, 17β-estradiol reduced the extent to which ectopic wildtype and mutant DISC1 aggregated. Furthermore, 17β-estradiol also caused the enrichment of synaptic proteins at synapses and increased the number of dendritic spines containing PSD-95 or that overlapped with the pre-synaptic marker bassoon. Taken together, our data indicates that estrogens can restore lost excitatory synapses caused by altered DISC1 expression, potentially through the trafficking of DISC1 and its interacting partners. These data highlight the possibility that estrogens exert their beneficial effects in SCZ and MDD in part by modulating dendritic spine number.

Polycystic Ovary Syndrome and Psychotic Disorder

Polycystic ovary syndrome (PCOS), a disease that usually emerges during adolescence, is characterized by hormonal imbalance and ovarian dysfunction. The prevalence can vary between 5.6 to 21.3% in women and 6% in adolescent girls. This discrepancy is related to the population studied and the diagnostic criteria used. The underlying pathophysiology of PCOS is not fully understood, but it can lead to a number of co-morbidities, including hypertension, diabetes, dyslipidemia, and also, mental health disorders. Clinical and preclinical data indicate neuroendocrine involvement with dysfunction in gamma-Aminobutyric acid (GABA) signaling and neuronal androgen receptors that might reduce hypothalamic sensitivity and lead to an impairment of estradiol and progesterone feedback. Based on these assumptions, the aims of this paper are to review the association of PCOS and psychotic disorders in order to address the burden of women comorbid for both conditions.