Lifetime reproductive output over two generations in patients with psychosis and their unaffected siblings: the Uppsala 1915-1929 Birth Cohort Multigenerational Study

An ERP Study of Face Processing in Schizophrenia, Bipolar Disorder, and Socially Isolated Individuals from the Community

People with schizophrenia (SCZ) and bipolar disorder (BD) have impairments in processing social information, including faces. The neural correlates of face processing are widely studied with the N170 ERP component. However, it is unclear whether N170 deficits reflect neural abnormalities associated with these clinical conditions or differences in social environments. The goal of this study was to determine whether N170 deficits would still be present in SCZ and BD when compared with socially isolated community members. Participants included 66 people with SCZ, 37 with BD, and 125 community members (76 "Community-Isolated"; 49 "Community-Connected"). Electroencephalography was recorded during a face processing task in which participants identified the gender of a face, the emotion of a face (angry, happy, neutral), or the number of stories in a building. We examined group differences in the N170 face effect (greater amplitudes for faces vs buildings) and the N170 emotion effect (greater amplitudes for emotional vs neutral expressions). Groups significantly differed in levels of social isolation (Community-Isolated > SCZ > BD = Community-Connected). SCZ participants had significantly reduced N170 amplitudes to faces compared with both community groups, which did not differ from each other. The BD group was intermediate and did not differ from any group. There were no significant group differences in the processing of specific emotional facial expressions. The N170 is abnormal in SCZ even when compared to socially isolated community members. Hence, the N170 seems to reflect a social processing impairment in SCZ that is separate from level of social isolation.

Origins of spousal cross-concordance for psychiatric disorders: a test of the social stress theory for alcohol use disorder

BACKGROUND

The authors sought to clarify the impact of spousal psychiatric disorders of differing severity [major depression or anxiety disorders (DAD) v. bipolar disorder or nonaffective psychosis (BPN)] on proband risk for alcohol use disorder (AUD) during marriage.

METHODS

In a Swedish cohort (N = 744 628), associations between spousal DAD and BPN and proband AUD were estimated with Cox proportional hazards; associations between parental AUD, proband premarital AUD, and spousal lifetime DAD and BPN were estimated with logistic regression; and whether spousal DAD or BPN causally increased risk for AUD was evaluated with frailty models.

RESULTS

Spousal premarital DAD, spousal marital-onset DAD, and spousal BPN (premarital or marital-onset) were associated with proband AUD during marriage [hazard ratios (HR) range 1.44-3.72]. Those with a parental or premarital history of AUD (v. without) were more likely to marry a spouse with DAD or BPN (odds ratios 1.22-2.77). Moving from an unaffected first spouse to a DAD-affected second spouse increased AUD risk in males (HR 2.90). Moving from an unaffected first spouse to a BPN-affected second spouse increased AUD risk (HRmales 3.96; HRfemales 5.64). Moving to an unaffected second spouse from a DAD-affected first spouse decreased AUD risk, with stronger evidence in females compared to males (HRmales 0.59; HRfemales 0.28).

CONCLUSIONS

Associations between spousal DAD or BPN and proband AUD reflect both selection and causal effects. Marriage to a BPN-affected spouse has a particularly strong effect on AUD risk, with more modest effects for spousal DAD.

General and age-specific fertility rates in non-affective psychosis: population-based analysis of Scottish women

PURPOSE

Women diagnosed with non-affective psychosis have a lower general fertility rate (GFR) and age-specific fertility rate (ASFR) than women in the general population. Contemporary data on GFR in this group remain limited, despite substantive changes in prescribing and management. We calculated contemporary estimates of the GFR and ASFR for women diagnosed with non-affective psychosis compared with the general population of women without this diagnosis.

METHODS

A population-based design combined routinely collected historical maternity and psychiatric data from two representative areas of Scotland. Women were included from the NHS Grampian or Greater Glasgow and Clyde areas and were aged 15-44 between 2005 and 2013 inclusive. The 'exposed' group had a diagnosis of non-affective psychosis (ICD-10 F20-F29) and was compared to the general population of 'unexposed' women in the same geographical areas.

RESULTS

Annual GFR between 2005 and 2013 for women with non-affective psychosis varied from 9.6 to 21.3 live births/1000 women per year in the exposed cohort and 52.7 to 57.8 live births/1000 women per year in the unexposed cohort, a rate ratio (RR) of 0.28 [p < 0.001; 95% CI (0.24, 0.32)]. ASFR for all 5-year age groups was lower in the exposed cohort than amongst unexposed women.

CONCLUSION

We highlight continued low fertility rates in women with a diagnosis of non-affective psychosis, despite widespread availability of prolactin-sparing atypical antipsychotics. Accurate estimation of fertility rates remains crucial in developing needs-matched perinatal care for these women. Methodological improvements using routine datasets to investigate perinatal mental health are also urgently needed.

Schizophrenia: the new etiological synthesis

Schizophrenia has been an evolutionary paradox: it has high heritability, but it is associated with decreased reproductive success. The causal genetic variants underlying schizophrenia are thought to be under weak negative selection. To unravel this paradox, many evolutionary explanations have been suggested for schizophrenia. We critically discuss the constellation of evolutionary hypotheses for schizophrenia, highlighting the lack of empirical support for most existing evolutionary hypotheses-with the exception of the relatively well supported evolutionary mismatch hypothesis. It posits that evolutionarily novel features of contemporary environments, such as chronic stress, low-grade systemic inflammation, and gut dysbiosis, increase susceptibility to schizophrenia. Environmental factors such as microbial infections (e.g., Toxoplasma gondii) can better predict the onset of schizophrenia than polygenic risk scores. However, researchers have not been able to explain why only a small minority of infected people develop schizophrenia. The new etiological synthesis of schizophrenia indicates that an interaction between host genotype, microbe infection, and chronic stress causes schizophrenia, with neuroinflammation and gut dysbiosis mediating this etiological pathway. Instead of just alleviating symptoms with drugs, the parasite x genotype x stress model emphasizes that schizophrenia treatment should focus on detecting and treating possible underlying microbial infection(s), neuroinflammation, gut dysbiosis, and chronic stress.

The EEG multiverse of schizophrenia

Research on schizophrenia typically focuses on one paradigm for which clear-cut differences between patients and controls are established. Great efforts are made to understand the underlying genetical, neurophysiological, and cognitive mechanisms, which eventually may explain the clinical outcome. One tacit assumption of these "deep rooting" approaches is that paradigms tap into common and representative aspects of the disorder. Here, we analyzed the resting-state electroencephalogram (EEG) of 121 schizophrenia patients and 75 controls. Using multiple signal processing methods, we extracted 194 EEG features. Sixty-nine out of the 194 EEG features showed a significant difference between patients and controls, indicating that these features detect an important aspect of schizophrenia. Surprisingly, the correlations between these features were very low. We discuss several explanations to our results and propose that complementing "deep" with "shallow" rooting approaches might help in understanding the underlying mechanisms of the disorder.

Cross-continental admixture in the Kho population from northwest Pakistan

Northern Pakistan is home to many diverse ethnicities and languages. The region acted as a prime corridor for ancient invasions and population migrations between Western Eurasia and South Asia. Kho, one of the major ethnic groups living in this region, resides in the remote and isolated mountainous region in the Chitral Valley of the Hindu Kush Mountain range. They are culturally and linguistically distinct from the rest of the Pakistani population groups and their genetic ancestry is still unknown. In this study, we generated genome-wide genotype data of ~1 M loci (Illumina WeGene array) for 116 unrelated Kho individuals and carried out comprehensive analyses in the context of worldwide extant and ancient anatomically modern human populations across Eurasia. The results inferred that the Kho can trace a large proportion of their ancestry to the population who migrated south from the Southern Siberian steppes during the second millennium BCE ~110 generations ago. An additional wave of gene flow from a population carrying East Asian ancestry was also identified in the Kho that occurred ~60 generations ago and may possibly be linked to the expansion of the Tibetan Empire during 7th to 9th centuries CE (current era) in the northwestern regions of the Indian sub-continent. We identified several candidate regions suggestive of positive selection in the Kho, that included genes mainly involved in pigmentation, immune responses, muscular development, DNA repair, and tumor suppression.

Altered working memory-related brain activity in children at familial high risk for psychosis: A preliminary study

BACKGROUND

Schizophrenia spectrum disorders are heritable illnesses that usually manifest in early adulthood but are increasingly viewed as neurodevelopmental disorders. Functional magnetic resonance imaging (fMRI) studies show altered brain activity during performance of working memory (WM) tasks in both individuals with schizophrenia and their first-degree relatives as compared to healthy controls (HC). This study examined whether similar changes are already present in pre-adolescent children at familial high-risk (FHR) for psychosis.

METHODS

37 children (17 FHR, 20 HC) between 7 and 12 years old participated in this study. WM performance was assessed using the Wechsler Intelligence Scale for Children-IV (WISC-IV). To assess brain activation during WM performance, participants completed a visual block-designed n-back task with 2 conditions (2-back and 0-back) during scanning. fMRI data was preprocessed and analyzed using FSL Feat.

RESULTS

Compared to HC, FHR children showed significantly lower WISC-IV WM scores. In addition, FHR children exhibited hypoactivation in the 2-back (versus 0-back) condition in a cluster encompassing bilateral precuneus and cuneus and right posterior cingulate cortex. There were no significant group-differences in n-back task performance and brain activation. The precuneus cluster was not correlated with n-back performance or WISC WM scores.

CONCLUSIONS

The current results provide preliminary evidence of impaired WM function and altered brain activity during WM performance in children with a familial predisposition for psychosis. Longitudinal studies are needed to determine whether these findings are related to abnormal brain development and predictive of cognitive deficits and psychosis later in life.

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.

Social exclusion and rejection across the psychosis spectrum: A systematic review of empirical research

Social exclusion and rejection have deleterious effects on psychological well-being. Research documents the negative effects of social exclusion and rejection on psychiatric problems like depression, social anxiety disorder, and non-suicidal self-injury. Additionally, prior research suggests that individuals with and at-risk for psychosis spectrum disorders may also be negatively affected by exclusion and rejection. Moreover, those on the psychosis spectrum may be at an even greater risk to experience social exclusion due to poor social functioning and the stigma surrounding the disorder. This systematic review aimed to investigate how individuals across the psychosis spectrum respond to social exclusion and rejection. We systematically searched PubMed and PsycINFO databases to identify studies that met the following eligibility criteria: 1) investigated social exclusion or rejection, 2) targeted a psychosis-related sample or symptoms, and 3) was an empirical study. 13 studies satisfied our eligibility criteria and were subsequently reviewed. Despite methodological variation and samples spanning the psychosis spectrum, the majority of the literature supports the conclusion that those with psychosis spectrum disorders report similar levels of exclusion-induced distress compared to healthy controls, but process and cope with exclusion differently, both behaviorally and neurobiologically.

Genomic Variation, Evolvability, and the Paradox of Mental Illness

Twentieth-century genetics was hard put to explain the irregular behavior of neuropsychiatric disorders. Autism and schizophrenia defy a principle of natural selection; they are highly heritable but associated with low reproductive success. Nevertheless, they persist. The genetic origins of such conditions are confounded by the problem of variable expression, that is, when a given genetic aberration can lead to any one of several distinct disorders. Also, autism and schizophrenia occur on a spectrum of severity, from mild and subclinical cases to the overt and disabling. Such irregularities reflect the problem of missing heritability; although hundreds of genes may be associated with autism or schizophrenia, together they account for only a small proportion of cases. Techniques for higher resolution, genomewide analysis have begun to illuminate the irregular and unpredictable behavior of the human genome. Thus, the origins of neuropsychiatric disorders in particular and complex disease in general have been illuminated. The human genome is characterized by a high degree of structural and behavioral variability: DNA content variation, epistasis, stochasticity in gene expression, and epigenetic changes. These elements have grown more complex as evolution scaled the phylogenetic tree. They are especially pertinent to brain development and function. Genomic variability is a window on the origins of complex disease, neuropsychiatric disorders, and neurodevelopmental disorders in particular. Genomic variability, as it happens, is also the fuel of evolvability. The genomic events that presided over the evolution of the primate and hominid lineages are over-represented in patients with autism and schizophrenia, as well as intellectual disability and epilepsy. That the special qualities of the human genome that drove evolution might, in some way, contribute to neuropsychiatric disorders is a matter of no little interest.

The Incidence of Nonaffective, Nonorganic Psychotic Disorders in Older People: A Population-based Cohort Study of 3 Million People in Sweden

BACKGROUND

There are limited data on the epidemiology of very late-onset schizophrenia-like psychosis (VLOSLP) and how this relates to potential risk factors including migration, sensory impairment, traumatic life events, and social isolation.

METHODS

We followed up a cohort of 3 007 378 people living in Sweden, born 1920-1949, from their 60th birthday (earliest: January 15, 1980) until December 30 2011, emigration, death, or first recorded diagnosis of nonaffective psychosis. We examined VLOSLP incidence by age, sex, region of origin, income, partner or child death, birth period, and sensory impairments.

RESULTS

We identified 14 977 cases and an overall incidence of 37.7 per 100 000 person-years at-risk (95% CI = 37.1-38.3), with evidence that rates increased more sharply with age for women (likelihood ratio test: χ2(6) = 31.56, P < .001). After adjustment for confounders, rates of VLOSLP were higher among migrants from Africa (hazard ratio [HR] = 2.0, 95% CI = 1.4-2.7), North America (HR = 1.4, 95% CI = 1.0-1.9, P = .04), Europe (HR = 1.3, 95% CI = 1.2-1.4), Russian-Baltic regions (HR = 1.6, 95% CI = 1.4-1.9), and Finland (HR = 1.6, 95% CI = 1.5-1.7). VLOSLP risk was highest for those in the lowest income quartile (HR = 3.1, 95% CI = 2.9-3.3). Rates were raised in those whose partner died 2 years before cohort exit (HR = 1.1, 95% CI = 1.0-1.3, P = .02) or whose child died in infancy (HR = 1.2, 95% CI = 1.0-1.4, P = .05), those without a partner (HR = 1.9, 95% CI = 1.8-1.9) or children (HR = 2.4, 95% CI = 2.3-2.5), and those whose child had a psychotic disorder (HR = 2.4, 95% CI = 2.2-2.6).

INTERPRETATION

We identified a substantial burden of psychosis incidence in old age, with a higher preponderance in women and most migrant groups. Life course exposure to environmental factors including markers of deprivation, isolation, and adversity were associated with VLOSLP risk.

Interrogating the Evolutionary Paradox of Schizophrenia: A Novel Framework and Evidence Supporting Recent Negative Selection of Schizophrenia Risk Alleles

Schizophrenia is a psychiatric disorder with a worldwide prevalence of ∼1%. The high heritability and reduced fertility among schizophrenia patients have raised an evolutionary paradox: why has negative selection not eliminated schizophrenia associated alleles during evolution? To address this question, we examined evolutionary markers, known as modern-human-specific (MD) sites and archaic-human-specific sites, using existing genome-wide association study (GWAS) data from 34,241 individuals with schizophrenia and 45,604 healthy controls included in the Psychiatric Genomics Consortium (PGC). By testing the distribution of schizophrenia single nucleotide polymorphisms (SNPs) with risk and protective effects in the human-specific sites, we observed a negative selection of risk alleles for schizophrenia in modern humans relative to archaic humans (e.g., Neanderthal and Denisovans). Such findings indicate that risk alleles of schizophrenia have been gradually removed from the modern human genome due to negative selection pressure. This novel evidence contributes to our understanding of the genetic origins of schizophrenia.

Psychiatric research in the Northern Finland Birth Cohort 1986 - a systematic review

The Northern Finland Birth Cohort 1986 is a large population-based birth cohort, which aims to promote health and wellbeing of the population. In this paper, we systematically review the psychiatric research performed in the cohort until today, i.e. at the age of 32 years of the cohort (2018). We conducted a systematic literature search using the databases of PubMed and Scopus and complemented it with a manual search. We found a total of 94 articles, which were classified as examining ADHD, emotional and behavioural problems, psychosis risk or other studies relating to psychiatric subjects. The articles are mainly based on two large comprehensive follow-up studies of the cohort and several substudies. The studies have often used also nationwide register data. The studies have found several early predictors for the aforementioned psychiatric outcomes, such as problems at pregnancy and birth, family factors in childhood, physical inactivity and substance use in adolescence. There are also novel findings relating to brain imaging and cognition, for instance regarding familial risk of psychosis in relation to resting state functional MRI. The Northern Finland Birth Cohort 1986 has been utilised frequently in psychiatric research and future data collections are likely to lead to new scientifically important findings.

Abbreviations: attention deficit hyperactivity disorder (ADHD); magnetic resonance imaging (MRI)

Artistic creativity and risk for schizophrenia, bipolar disorder and unipolar depression: a Swedish population-based case-control study and sib-pair analysis

BACKGROUND

Many studies have addressed the question of whether mental disorder is associated with creativity, but high-quality epidemiological evidence has been lacking.AimsTo test for an association between studying a creative subject at high school or university and later mental disorder.

METHOD

In a case-control study using linked population-based registries in Sweden (N = 4 454 763), we tested for associations between tertiary education in an artistic field and hospital admission with schizophrenia (N = 20 333), bipolar disorder (N = 28 293) or unipolar depression (N = 148 365).

RESULTS

Compared with the general population, individuals with an artistic education had increased odds of developing schizophrenia (odds ratio = 1.90, 95% CI = [1.69; 2.12]) bipolar disorder (odds ratio = 1.62 [1.50; 1.75]) and unipolar depression (odds ratio = 1.39 [1.34; 1.44]. The results remained after adjustment for IQ and other potential confounders.

CONCLUSIONS

Students of artistic subjects at university are at increased risk of developing schizophrenia, bipolar disorder and unipolar depression in adulthood.Declaration of interestNone.

Positive Traits in the Bipolar Spectrum: The Space between Madness and Genius

Bipolar disorder is a severe, lifelong mood disorder for which little is currently understood of the genetic mechanisms underlying risk. By examining related dimensional phenotypes, we may further our understanding of the disorder. Creativity has a historical connection with the bipolar spectrum and is particularly enhanced among unaffected first-degree relatives and those with bipolar spectrum traits. This suggests that some aspects of the bipolar spectrum may confer advantages, while more severe expressions of symptoms negatively influence creative accomplishment. Creativity is a complex, multidimensional construct with both cognitive and affective components, many of which appear to reflect a shared genetic vulnerability with bipolar disorder. It is suggested that a subset of bipolar risk variants confer advantages as positive traits according to an inverted-U-shaped curve with clinically unaffected allele carriers benefitting from the positive traits and serving to maintain the risk alleles in the population. The association of risk genes with creativity in healthy individuals (e.g., NRG1), as well as an overall sharing of common genetic variation between bipolar patients and creative individuals, provides support for this model. Current findings are summarized from a multidisciplinary perspective to demonstrate the feasibility of research in this area to reveal the mechanisms underlying illness.

Social relationships in young adults at ultra high risk for psychosis

Studies suggest that individuals with schizophrenia have smaller social networks and less satisfying relationships. However, much is still unknown about the typical quantity and quality of social relationships in young adults during the ultra high-risk (UHR) period. Investigating these relationships holds significant importance for improving understanding of etiological processes, mapping the social environment, and highlighting treatment targets in a critical period. A total of 85 participants (44 UHR and 41 healthy controls) completed measures examining the participants' social relationships, social support, and loneliness. Mean differences between the UHR and healthy control participants and associations between social relationships and symptoms and functioning were examined. Results indicated significant differences between groups on several indices. Specifically, the UHR youth reported fewer close friends, less diverse social networks, less perceived social support, poorer relationship quality with family and friends, and more loneliness. Notably, within the UHR group, being lonely and having fewer and worse quality relationships was associated with greater symptom severity and lower overall functioning. This study suggests that youth at high-risk of developing psychosis have fewer and poorer quality social relationships. Interventions that focus on increasing the quantity and quality of young adults' social networks may be beneficial for this population.

Parenthood among patients with psychotic disorders: gender differences in a non-selective clinical sample

A large proportion of people with psychotic disorders have children and also live with them. However, research has rarely studied this in clinical populations and included male patients. This exploratory study used routine data of all 709 patients with a psychotic disorder treated in a psychiatric inpatient service in Austria between 2012 and 2015. Socio-demographic and clinical characteristics, number and age of children, and living arrangements were assessed and analysed. More female patients than male patients had children in the total sample (56% vs. 30%), and in diagnostic subgroups with bipolar disorder (71%, 53%), schizoaffective disorder (65%, 24%), and schizophrenia (45%, 21%). Being female, higher age, and living with a partner were associated with having children. Unlike female patients, most male patients with underage children (≤18 years) did not live with them, especially when patients had a diagnosis of schizophrenia. The gender specific differences in parenthood and custody arrangements identified in this study indicate different support needs of mothers and fathers with psychotic disorders. Not living with a child and having limited access might come with feelings of guilt and loss, which should be addressed in research and practice.

Evidence for Genetic Overlap Between Schizophrenia and Age at First Birth in Women

IMPORTANCE

A recently published study of national data by McGrath et al in 2014 showed increased risk of schizophrenia (SCZ) in offspring associated with both early and delayed parental age, consistent with a U-shaped relationship. However, it remains unclear if the risk to the child is due to psychosocial factors associated with parental age or if those at higher risk for SCZ tend to have children at an earlier or later age.

OBJECTIVE

To determine if there is a genetic association between SCZ and age at first birth (AFB) using genetically informative but independently ascertained data sets.

DESIGN, SETTING, AND PARTICIPANTS

This investigation used multiple independent genome-wide association study data sets. The SCZ sample comprised 18 957 SCZ cases and 22 673 controls in a genome-wide association study from the second phase of the Psychiatric Genomics Consortium, and the AFB sample comprised 12 247 genotyped women measured for AFB from the following 4 community cohorts: Estonia (Estonian Genome Center Biobank, University of Tartu), the Netherlands (LifeLines Cohort Study), Sweden (Swedish Twin Registry), and the United Kingdom (TwinsUK). Schizophrenia genetic risk for each woman in the AFB community sample was estimated using genetic effects inferred from the SCZ genome-wide association study.

MAIN OUTCOMES AND MEASURES

We tested if SCZ genetic risk was a significant predictor of response variables based on published polynomial functions that described the relationship between maternal age and SCZ risk in offspring in Denmark. We substituted AFB for maternal age in these functions, one of which was corrected for the age of the father, and found that the fit was superior for the model without adjustment for the father's age.

RESULTS

We observed a U-shaped relationship between SCZ risk and AFB in the community cohorts, consistent with the previously reported relationship between SCZ risk in offspring and maternal age when not adjusted for the age of the father. We confirmed that SCZ risk profile scores significantly predicted the response variables (coefficient of determination R2 = 1.1E-03, P = 4.1E-04), reflecting the published relationship between maternal age and SCZ risk in offspring by McGrath et al in 2014.

CONCLUSIONS AND RELEVANCE

This study provides evidence for a significant overlap between genetic factors associated with risk of SCZ and genetic factors associated with AFB. It has been reported that SCZ risk associated with increased maternal age is explained by the age of the father and that de novo mutations that occur more frequently in the germline of older men are the underlying causal mechanism. This explanation may need to be revised if, as suggested herein and if replicated in future studies, there is also increased genetic risk of SCZ in older mothers.

Relationship between prolactin, breast cancer risk, and antipsychotics in patients with schizophrenia: a critical review

OBJECTIVE

A recent meta-analysis showed that breast cancer probably is more common in female patients with schizophrenia than in the general population (effect size = 1.25, P < 0.05). Increasing experimental and epidemiological data have alerted researchers to the influence of prolactin (PRL) in mammary carcinogenesis. We therefore investigated the possible relationship between antipsychotic-induced hyperprolactinemia (HPRL) and breast cancer risk in female patients with schizophrenia.

METHOD

A literature search (1950 until January 2015), using the MEDLINE database, was conducted for English-language published clinical trials to identify and synthesize data of the current state of knowledge concerning breast cancer risk (factors) in women with schizophrenia and its (their) relationship between HPRL and antipsychotic medication.

RESULTS

Although an increasing body of evidence supports the involvement of PRL in breast carcinogenesis, results of human prospective studies are limited, equivocal, and correlative (with risk ratios ranging from 0.70 to 1.9 for premenopausal women and from 0.76 to 2.03 for postmenopausal women). Moreover, these studies equally do not take into account the local production of PRL in breast epithelium, although amplification or overexpression of the local autocrine/paracrine PRL loop may be a more important mechanism in tumorigenesis. Until now, there is also no conclusive evidence that antipsychotic medication can increase the risk of breast malignancy and mortality.

CONCLUSION

Other breast risk factors than PRL, such as nulliparity, obesity, diabetes mellitus, and unhealthy lifestyle behaviours (alcohol dependence, smoking, low physical activity), probably are of greater relevance in individual breast cancer cases within the population of female patients with schizophrenia.

The Concept of Schizophrenia: From Unity to Diversity

After over 100 years of research without clarifying the aetiology of schizophrenia, a look at the current state of knowledge in epidemiology, genetics, precursors, psychopathology, and outcome seems worthwhile. The disease concept, created by Kraepelin and modified by Bleuler, has a varied history. Today, schizophrenia is considered a polygenic disorder with onset in early adulthood, characterized by irregular psychotic episodes and functional impairment, but incident cases occur at all ages with marked differences in symptoms and social outcome. Men’s and women’s lifetime risk is nearly the same. At young age, women fall ill a few years later and less severely than men, men more rarely and less severely later in life. The underlying protective effect of oestrogen is antagonized by genetic load. The illness course is heterogeneous and depressive mood the most frequent symptom. Depression and schizophrenia are functionally associated, and affective and nonaffective psychoses do not split neatly. Most social consequences occur at the prodromal stage. Neither schizophrenia as such nor its main symptom dimensions regularly show pronounced deterioration over time. Schizophrenia is neither a residual state of a neurodevelopmental disorder nor a progressing neurodegenerative process. It reflects multifactorial CNS instability, which leads to cognitive deficits and symptom exacerbations.

Pre-morbid fertility in psychosis: findings from the AESOP first episode study

Individuals with psychotic illnesses are known to have a reduced fertility. It is unclear whether this is due to biological or social factors. Most fertility studies have been conducted in chronic schizophrenia, where confounders like medication and hospitalisation make this difficult to elicit. A less severe reduction of fertility has been observed in some ethnic minorities, but results are inconsistent. We sought to investigate pre-morbid fertility in an ethnically diverse sample of individuals with first-onset psychosis. Data were derived from 515 people with a first psychotic episode (FEP) and 383 controls. We made case-control comparisons of differences in the proportion of those with children (fertility rates) and mean number of children (MNC). Analyses were then stratified by diagnosis, gender and ethnicity, and adjusted for potential confounders. We found that FEP showed a reduced fertility rate (age-adjusted OR of having children 0.47 [95% CI=0.39, 0.56]), irrespective of diagnosis, and there was little evidence of confounding by gender, ethnicity, religious background, education level, or history of past relationships (fully adjusted OR=0.55, 95% CI=0.37, 0.80). Women had a somewhat greater reduction in fertility rates than men (Men: age-adjusted OR 0.61 [95% CI 0.42, 0.89]; Women: age-adjusted OR 0.46 [95% CI 0.31, 0.69]) and we could not find any evidence of ethnic differences in the degree of fertility reduction. FEP who had previously experienced a stable relationship had an MNC that was comparable to that of the general population and had a later onset of illness. This is the largest case-control study to date to investigate fertility in first-onset psychosis. Our data suggests that fertility is affected, even prior to the onset of a psychotic illness, and there are likely to be biological and environmental factors involved, but the former seem to have a stronger influence.

Neurocognition: clinical and functional outcomes in schizophrenia

Schizophrenia is characterized by significant heterogeneity in outcome. The last decades have witnessed a significant interest in identifying factors that can moderate or influence clinical and functional outcomes in people with schizophrenia. One factor of particular interest is neurocognition, as performance on various measures of cognitive abilities, such as memory, attention, and executive functions, have been consistently related to functional outcome and, to a lesser extent, clinical outcome. This review aims to provide an up-to-date description of recent studies examining the association between neurocognition and clinical and (or) functional outcomes. In the first section, studies examining neurocognitive performance in relation to clinical outcome are examined. When clinical outcome is defined dichotomously (for example, comparing remitted and nonremitted), verbal memory performance consistently exhibits a strong association with clinical status, with the poor outcome group showing the largest deficits. In the second section, studies exploring the relation between neurocognition and various dimensions of functional outcome are reviewed. These dimensions include independent living, social functioning, and vocational functioning, among others. Again, a strong link between neurocognitive deficits and impairments in several aspects of functioning clearly emerges from this review. Finally, several measurement issues are discussed that pertain to the need to standardize definitions of clinical and (or) functional outcomes, the importance of defining cognitive domains consistently across studies, and distinguishing between one's competence to perform tasks and what one actually does in everyday life. Addressing these measurement issues will be key to studies examining the development of effective interventions targeting neurocognitive functions and their impact on clinical and functional outcomes.

Reproductive health in women with serious mental illnesses

AIMS AND OBJECTIVES

To determine what problems female psychiatric patients have in terms of reproductive health.

BACKGROUND

The reproductive health problems faced by female psychiatric patients are matters that have been neglected in the areas of both psychiatry and women's health. This study aims to make a contribution from Turkey to the literature in this neglected field.

DESIGN

The study is descriptive and was conducted with 292 female patients treated in an acute inpatient psychiatric ward.

METHODS

Data were collected through face-to-face interviews and a questionnaire based on the literature and prepared by the researchers which was designed to determine the kinds of reproductive health issues the patients were experiencing.

RESULTS

It was found that compared with healthy women, the distinctive features of the participants in terms of sexuality were more negative; in particular, patients diagnosed with bipolar disorder were more likely to have been forced by their partners to have sex, they had suffered from rape or sexually transmitted diseases, the majority of those who had previous sexual experience had tried to use contraceptives but had been unable to continue using them, they were most likely to choose the method of withdrawal for contraception, their rates of pregnancy and abortion were high, they received less antenatal care, and they were more likely to have smoked during pregnancy.

CONCLUSIONS

It was found that female patients with psychiatric disorders had more negative attributes with regard to marriage, sexuality, family planning, maternal characteristics and pregnancy, compared with a corresponding healthy population.

RELEVANCE TO CLINICAL PRACTICE

The results of this study may be useful for nurses in the clinical field for calling an attention and raising an awareness of the reproductive health problems of women with psychiatric disorders, taking the necessary preventive measures, and developing damage-reducing strategies.

The evolutionary paradox and the missing heritability of schizophrenia

Schizophrenia is one of the most detrimental common psychiatric disorders, occurring at a prevalence of approximately 1%, and characterized by increased mortality and reduced reproduction, especially in men. The heritability has been estimated around 70% and the genome-wide association meta-analyses conducted by the Psychiatric Genomics Consortium have been successful at identifying an increasing number of risk loci. Various theories have been proposed to explain why genetic variants that predispose to schizophrenia persist in the population, despite the fitness reduction in affected individuals, a question known as the evolutionary paradox. In this review, we consider evolutionary perspectives of schizophrenia and of the empirical evidence that may support these perspectives. Proposed evolutionary explanations include balancing selection, fitness trade-offs, fluctuating environments, sexual selection, mutation-selection balance and genomic conflicts. We address the expectations about the genetic architecture of schizophrenia that are predicted by different evolutionary scenarios and discuss the implications for genetic studies. Several potential sources of "missing" heritability, including gene-environment interactions, epigenetic variation, and rare genetic variation are examined from an evolutionary perspective. A better understanding of evolutionary history may provide valuable clues to the genetic architecture of schizophrenia and other psychiatric disorders, which is highly relevant to genetic studies that aim to detect genetic risk variants.

Temporal trends in general and age-specific fertility rates among women with schizophrenia (1996-2009): a population-based study in Ontario, Canada

PURPOSE

There is substantial evidence that women with schizophrenia in many parts of the world have fewer children than their peers. Our objective was to analyze recent trends in general and age-specific fertility rates among women with schizophrenia in Ontario, Canada.

METHODS

We conducted a repeated cross-sectional population-based study from 1996 to 2009 using population-based linked administrative databases for the entire province of Ontario. Women aged 15-49 years were classified into schizophrenia and non-schizophrenia groups in each successive 12-month period. Annual general and age-specific fertility rates were derived.

RESULTS

The general fertility rate (GFR) among women with schizophrenia was 1.16 times higher in 2007-2009 than in 1996-1998 (95% confidence interval [CI] 1.04-1.31). The annual GFR ratio of women with vs. without schizophrenia was 0.41 (95% CI 0.36-0.47) in 2009, which was slightly higher than the same ratio in 1996 of 0.30 (95% CI 0.25-0.35). Annual age-specific fertility rates (ASFR) increased over time among women with schizophrenia aged 20-24, 25-29, 35-39 and 40-44 years, but the increase was not always statistically significant. Among women aged 20-24 years, the ASFR ratio in women with vs. without schizophrenia was not significant by the end of the study period (0.93, 95% CI 0.70-1.22).

CONCLUSIONS

The general fertility rate among women with schizophrenia appears to have increased modestly over the past 13 years. Clinical care and health policy should consider new strategies that focus on the mental health of women with schizophrenia as new mothers, while optimizing healthy pregnancies and child rearing.

Preventing breast cancer in women with schizophrenia

OBJECTIVE

To record risk factors for breast cancer in women with schizophrenia and recommend preventive actions.

METHOD

A PubMed literature search (from 2005 to 2010) was conducted, using the search terms 'schizophrenia', 'antipsychotics', 'breast cancer' and 'risk factors'.

RESULTS

Several risk factors of relevance to schizophrenia were identified: obesity, elevated prolactin levels, low participation in mammography screening, high prevalence of diabetes, comparatively low parity, low incidence of breastfeeding, social disadvantage, high levels of smoking and alcohol consumption, low activity levels.

CONCLUSION

Awareness of breast cancer risk should lead to more accurate risk ascertainment, stronger linkage with primary care, regular monitoring and screening, judicious choice and low dose of antipsychotic treatment, concomitant use of adjunctive cognitive and psychosocial therapies, referral to diet and exercise programmes as well as smoking and drinking cessation programmes, avoidance of hormonal treatment and discussion with patient and family about the pros and cons of preventive measures in high-risk women. Psychiatrists are in a position to reverse many of the identified risk factors.

A systematic review and meta-analysis of the fertility of patients with schizophrenia and their unaffected relatives

OBJECTIVE

We aimed to systematically evaluate the empirical evidence for the commonly held view that the reduced reproductive output in patients with schizophrenia is compensated for by an increased fitness in unaffected relatives. Secondary aims were to quantify the magnitude of the fertility disadvantage and the apparent gender difference in fertility of patients with schizophrenia.

METHOD

We carried out a systematic review and meta-analysis of studies investigating the fertility of patients with schizophrenia, their siblings, their parents and the general population.

RESULTS

Patients with schizophrenia had reduced fertility compared with the general population, [Fertility Ratio (FR)=0.39 (95% Confidence Interval (CI)=0.35-0.44)]. Siblings of patients with schizophrenia had somewhat fewer offspring than the general population (FR=0.96, 95% CI=0.93-1.00). Parents of patients with schizophrenia had fertility similar to the general population (FR=1.17, 95% CI=0.94-1.46). Men had a greater impairment in fertility than women, both in patients (FR=0.54, 95% CI=0.50-0.57) and in their unaffected siblings (FR=0.81, 95% CI=0.71-0.92).

CONCLUSION

Compensatory fitness advantage in siblings and parents cannot explain the maintenance of schizophrenia in the population. Alternative explanations include mutation-selection balance and the role of quantitative traits.

Reduced fertility in patients' families is consistent with the sexual selection model of schizophrenia and schizotypy

Background

Schizophrenia is a mental disorder marked by an evolutionarily puzzling combination of high heritability, reduced reproductive success, and a remarkably stable prevalence. Recently, it has been proposed that sexual selection may be crucially involved in the evolution of schizophrenia. In the sexual selection model (SSM) of schizophrenia and schizotypy, schizophrenia represents the negative extreme of a sexually selected indicator of genetic fitness and condition. Schizotypal personality traits are hypothesized to increase the sensitivity of the fitness indicator, thus conferring mating advantages on high-fitness individuals but increasing the risk of schizophrenia in low-fitness individuals; the advantages of successful schzotypy would be mediated by enhanced courtship-related traits such as verbal creativity. Thus, schizotypy-increasing alleles would be maintained by sexual selection, and could be selectively neutral or even beneficial, at least in some populations. However, most empirical studies find that the reduction in fertility experienced by schizophrenic patients is not compensated for by increased fertility in their unaffected relatives. This finding has been interpreted as indicating strong negative selection on schizotypy-increasing alleles, and providing evidence against sexual selection on schizotypy.

Methodology

A simple mathematical model is presented, showing that reduced fertility in the families of schizophrenic patients can coexist with selective neutrality of schizotypy-increasing alleles, or even with positive selection on schizotypy in the general population. If the SSM is correct, studies of patients' families can be expected to underestimate the true fertility associated with schizotypy.

Significance

This paper formally demonstrates that reduced fertility in the families of schizophrenic patients does not constitute evidence against sexual selection on schizotypy-increasing alleles. Futhermore, it suggests that the fertility estimates derived from extant studies may be biased to an unknown extent. These results have important implications for the evolutionary genetics of psychosis.

Social Factors in Schizophrenia

One of the defining characteristics of schizophrenia is impaired social functioning. This was recognized a century ago in the earliest clinical descriptions of the disorder. Today, deterioration of social relations remains a hallmark of schizophrenia, with social isolation and withdrawal forming part of its clinical profile in the Diagnostic and Statistical Manual of Mental Disorders. But what kind of social problems do patients with schizophrenia have? When do they become apparent? Who is most affected? In this article, I present a brief review of what is currently known and highlight issues that still require attention from researchers. In addition to describing the social deficits associated with schizophrenia, I also consider some of the social consequences that may arise from these deficits. These consequences include social rejection, stigma, and problematic family relationships. I also consider the role of social-skills training in improving patients’ general social functioning and the clinical course of their disease.

Reproductive patterns in psychotic patients

CONTEXT

Longitudinal epidemiological studies have shown worse outcomes in patients with psychotic disorder than in the general population. The reproductive pattern may be seen as a measure of outcome following psychotic disorder onset, and it may be measured as the rate of child births where the rate is a proxy measure of well-being.

OBJECTIVE

To examine reproductive patterns following psychotic disorder onset by comparing the fertility rates of patients with schizophrenia and bipolar disorder with those of other psychiatric patients and the general population, taking into account parental status at disease-onset, time since onset, and the possible effect of abortions-rates.

METHODS

A prospective register-based cohort study drawing on the entire Danish population born after 1950. Incidence Rate Ratios (IRRs) of fertility were analysed using survival analysis.

RESULTS

Compared with the general population, the lowest first-child fertility rate was found among men (IRR=0.10) and women (IRR=0.18) with schizophrenia. In comparison, bipolar male patients had an IRR=0.32 and female patients an IRR=0.36, while male unipolar patients had an IRR=0.46 and female patients an IRR=0.57. In the group with other psychiatric disorders men had an IRR=0.51 and women an IRR=0.70.

CONCLUSIONS

The results of the present study show a selection process where persons with more severe disorders are less likely to become parents. The reduced fertility was strongly influenced by the time since psychiatric disorder onset; thus, the longer the time since onset, the higher the fertility.

The role of genetics in the etiology of schizophrenia

Schizophrenia is a complex genetic disorder manifesting combined environmental and genetic causation. Recently, genome-wide association experiments yielded remarkable new experimental evidence that is leading to a better understanding of the genetic models and the biological risk factors involved in schizophrenia. These studies have discovered uncommon copy number variations (mainly deletions) and common single nucleotide polymorphisms with alleles associated with schizophrenia. The aggregate data provide support for polygenic inheritance and for genetic overlap of schizophrenia with autism and with bipolar disorder. It is anticipated that the application of a myriad of tools from systems biology, in combination with biological functional experiments, will lead to a delineation of biological pathways involved in the pathophysiology of schizophrenia, and eventually to new therapies.

Excellent school performance at age 16 and risk of adult bipolar disorder: national cohort study

BACKGROUND

Anecdotal and biographical reports suggest that bipolar disorder may be associated with high IQ or creativity, but evidence for any such connection is weak.

AIMS

To investigate possible associations between scholastic achievement and later bipolar disorder, using prospective data, in a whole-population cohort study.

METHOD

Using individual school grades from all individuals finishing compulsory schooling in Sweden between 1988 and 1997, we tested associations between scholastic achievement at age 15-16 and hospital admission for psychosis between ages 17 and 31, adjusting for potential confounders.

RESULTS

Individuals with excellent school performance had a nearly fourfold increased risk of later bipolar disorder compared with those with average grades (hazard ratio HR = 3.79, 95% CI 2.11-6.82). This association appeared to be confined to males. Students with the poorest grades were also at moderately increased risk of bipolar disorder (HR = 1.86, 95% CI 1.06-3.28).

CONCLUSIONS

These findings provide support for the hypothesis that exceptional intellectual ability is associated with bipolar disorder.

Epigenetics, genomic mutations and cognitive function

INTRODUCTION

There is growing interest in the role of single genes in cognitive functions. Association studies are the most commonly applied method in this field. This method assumes that the genetic information affecting cognitive processes is "static" and unchanging. However, there is accumulating evidence that dynamic genomic and epigenetic alterations can modulate complex cognitive processes, and influence susceptibility to disorders associated with impaired cognitive functioning.

METHODS

We present an overview of genomic and epigenetic mechanisms, and discuss the cognitive and psychiatric consequences of genomic and genetic abnormalities.

RESULTS

Genomic and epigenetic changes can affect complex cognitive functions, including learning and memory and are causative in several developmental and psychiatric disorders effecting language, social functioning and IQ.

CONCLUSIONS

Genomic and epigenetic disorders are "experiments of nature" that offer unique and valuable insight in to the physiology of general and specific cognitive functions.