Divergent trajectories of physical, cognitive, and psychosocial aging in schizophrenia

Different psychopathological courses between chronic interictal psychosis and schizophrenia

OBJECTIVE

The clinical course of interictal psychosis (IIP) has not yet been investigated. We aimed to compared the psychopathology and time-relevant indices between chronic IIP (CIIP) and schizophrenia (SC) METHODS: In this comprehensive psychopathological study, patients with chronic psychosis with and without epilepsy (127 with CIIP and 187 with SC) were compared. Psychopathology was measured using the Brief Psychiatric Rating Scale (BPRS): total, negative symptoms (NSs), positive symptoms (PSs), and anxiety-depressive symptoms (ADSs). Time-relevant indices included age at the time of evaluation, age at the onset of psychosis, and duration of psychosis. The psychopathology of psychosis types and time-relevant indices were analyzed using Pearson's correlation coefficient analysis of covariance.

RESULTS

　Age at the time of evaluation was significantly correlated with NS, and ADS scores. Age-relevant trajectories significantly interacted with psychosis types. As age advanced, patients with SC exhibited increased scores, whereas patients with CIIP often exhibited decreased (or unchanged) scores. Age at onset of psychosis was significantly correlated with NS and ADS outcomes in patients with CIIP, whereas it was not correlated in patients with SC. There were significant interactions between age at onset and psychosis types. Patients with early-onset CIIP exhibited higher NS and lower ADS scores, whereas patients with SC exhibited no particular trajectory. The duration of psychosis significantly interacted with the psychosis types in the BPRS total, NSs and PSs. As duration increased, patients with CIIP exhibited no significant relationship, whereas patients with SC exhibited significantly higher psychotic scores.

CONCLUSION

Psychopathological courses differ between patients with CIIP and SC. Although patients with SC often exhibit deteriorations in psychotic symptoms, patients with CIIP exhibit no distinct deterioration. These findings can contribute psychiatric nosology, treatment strategies, and prediction outcomes.

Rest-activity rhythm disruption and metabolic health in schizophrenia: a cross-sectional actigraphy study of community-dwelling people living with schizophrenia and nonpsychiatric comparison participants

STUDY OBJECTIVES

People living with schizophrenia (PLWS) have increased physical comorbidities and premature mortality which may be linked to dysregulated rest-activity rhythms (RARs). This study aimed to compare RARs between PLWS and nonpsychiatric comparison participants (NCs) and to examine the relationships of RARs with age, sleep, metabolic, and physical health outcomes and, among PLWS, relationships of RARs with illness-related factors.

METHODS

The study sample included 26 PLWS and 36 NCs, assessed with wrist-worn actigraphy to compute RAR variables and general sleep variables. Participants completed assessments for clinical symptoms, physical health, sleep quality, medication use, and assays for fasting glycosylated hemoglobin (hemoglobin A1c) levels. We examined group differences in RAR and sleep variables, relationships of RAR variables with metabolic and physical health measures, and, among PLWS, relationships between RAR variables and illness-related measures.

RESULTS

PLWS had significantly shorter active periods, lower relative amplitude, and lower mean activity during their most active 10 hours compared to the NCs (Cohen's d = 0.79, 0.58, and 0.62, respectively). PLWS had poorer sleep quality, greater mean percent sleep, less wake after sleep onset, and higher total sleep time variability compared to NCs. PLWS had higher rates of antidepressant, anxiolytic, and antipsychotic medication use compared to NCs, which may have impacted sleep quality and objective sleep measures. Across both groups, more fragmented and variable RARs were associated with higher HbA1c levels (ηp2 = .10) and worse physical health (ηp2 = .21). Among PLWS, RARs were correlated with total sleep time (rs = .789, P < .01) and percent sleep (rs = .509, P < .05), but not with age, sleep quality, or other illness-related factors.

CONCLUSIONS

RARs provide unique information about sleep and activity for PLWS and have the potential for targeted interventions to improve metabolic health and mortality.

CITATION

Mahmood Z, Ramsey A, Kidambi N, et al. Rest-activity rhythm disruption and metabolic health in schizophrenia: a cross-sectional actigraphy study of community-dwelling people living with schizophrenia and nonpsychiatric comparison participants. J Clin Sleep Med. 2024;20(9):1505-1516.

Accelerated Pace of Aging in Schizophrenia: Five Case-Control Studies

BACKGROUND

Schizophrenia is associated with increased risk of developing multiple aging-related diseases, including metabolic, respiratory, and cardiovascular diseases, and Alzheimer's and related dementias, leading to the hypothesis that schizophrenia is accompanied by accelerated biological aging. This has been difficult to test because there is no widely accepted measure of biological aging. Epigenetic clocks are promising algorithms that are used to calculate biological age on the basis of information from combined cytosine-phosphate-guanine sites (CpGs) across the genome, but they have yielded inconsistent and often negative results about the association between schizophrenia and accelerated aging. Here, we tested the schizophrenia-aging hypothesis using a DNA methylation measure that is uniquely designed to predict an individual's rate of aging.

METHODS

We brought together 5 case-control datasets to calculate DunedinPACE (Pace of Aging Calculated from the Epigenome), a new measure trained on longitudinal data to detect differences between people in their pace of aging over time. Data were available from 1812 psychosis cases (schizophrenia or first-episode psychosis) and 1753 controls. Mean chronological age was 38.9 (SD = 13.6) years.

RESULTS

We observed consistent associations across datasets between schizophrenia and accelerated aging as measured by DunedinPACE. These associations were not attributable to tobacco smoking or clozapine medication.

CONCLUSIONS

Schizophrenia is accompanied by accelerated biological aging by midlife. This may explain the wide-ranging risk among people with schizophrenia for developing multiple different age-related physical diseases, including metabolic, respiratory, and cardiovascular diseases, and dementia. Measures of biological aging could prove valuable for assessing patients' risk for physical and cognitive decline and for evaluating intervention effectiveness.

Schizophrenia: Communication Disorders and Role of the Speech-Language Pathologist

PURPOSE

This clinical focus article aims to provide a comprehensive overview of schizophrenia and understanding of communication disorders resulting from its psychopathology. Schizophrenia is a spectrum disorder with varying levels of symptom expression. It is characterized by positive and negative symptoms that can cause communication disorders of different severity levels. Communication difficulties manifest as a range of symptoms such as alogia, disorganized speech, and impaired social communication. These challenges may result in receptive and expressive language deficits that lead to misunderstandings, reduced social interactions, and difficulties expressing thoughts and emotions effectively. The purpose of this clinical focus article is to explore the role of the speech-language pathologist (SLP) in assessing and treating communication disorders presented in schizophrenia.

CONCLUSIONS

In order to understand the role of the SLP in assessing and treating communication disorders in schizophrenia, it is imperative to understand the overall course, etiology, assessment, and treatment consideration of this condition. SLPs can provide services in the areas of social skills training and community-based intervention contexts.

Tract-based analyses of white matter in schizophrenia, bipolar disorder, aging, and dementia using high spatial and directional resolution diffusion imaging: a pilot study

Introduction

Structural brain connectivity abnormalities have been associated with several psychiatric disorders. Schizophrenia (SCZ) is a chronic disabling disorder associated with accelerated aging and increased risk of dementia, though brain findings in the disorder have rarely been directly compared to those that occur with aging.

Methods

We used an automated approach to reconstruct key white matter tracts and assessed tract integrity in five participant groups. We acquired one-hour-long high-directional diffusion MRI data from young control (CON, n =28), bipolar disorder (BPD, n =21), and SCZ (n =22) participants aged 18-30, and healthy elderly (ELD, n =15) and dementia (DEM, n =9) participants. Volume, fractional (FA), radial diffusivity (RD) and axial diffusivity (AD) of seven key white matter tracts (anterior thalamic radiation, ATR; dorsal and ventral cingulum bundle, CBD and CBV; corticospinal tract, CST; and the three superior longitudinal fasciculi: SLF-1, SLF-2 and SLF-3) were analyzed with TRACULA. Group comparisons in tract metrics were performed using multivariate and univariate analyses. Clinical relationships of tract metrics with recent and chronic symptoms were assessed in SCZ and BPD participants.

Results

A MANOVA showed group differences in FA (λ=0.5; p=0.0002) and RD (λ=0.35; p<0.0001) across the seven tracts, but no significant differences in tract AD and volume. Post-hoc analyses indicated lower tract FA and higher RD in ELD and DEM groups compared to CON, BPD and SCZ groups. Lower FA and higher RD in SCZ compared to CON did not meet statistical significance. In SCZ participants, a significant negative correlation was found between chronic psychosis severity and FA in the SLF-1 (r= -0.45; p=0.035), SLF-2 (r= -0.49; p=0.02) and SLF-3 (r= -0.44; p=0.042).

Discussion

Our results indicate impaired white matter tract integrity in elderly populations consistent with myelin damage. Impaired tract integrity in SCZ is most prominent in patients with advanced illness.

Overview of late-onset psychoses

BACKGROUND

Several etiologies can underlie the development of late-onset psychosis, defined by first psychotic episode after age 40 years. Late-onset psychosis is distressing to patients and caregivers, often difficult to diagnose and treat effectively, and associated with increased morbidity and mortality.

METHODS

The literature was reviewed with searches in Pubmed, MEDLINE, and the Cochrane library. Search terms included "psychosis," "delusions," hallucinations," "late onset," "secondary psychoses," "schizophrenia," bipolar disorder," "psychotic depression," "delirium," "dementia," "Alzheimer's," "Lewy body," "Parkinson's, "vascular dementia," and "frontotemporal dementia." This overview covers the epidemiology, clinical features, neurobiology, and therapeutics of late-onset psychoses.

RESULTS

Late-onset schizophrenia, delusional disorder, and psychotic depression have unique clinical characteristics. The presentation of late-onset psychosis requires investigation for underlying etiologies of "secondary" psychosis, which include neurodegenerative, metabolic, infectious, inflammatory, nutritional, endocrine, and medication toxicity. In delirium, psychosis is common but controlled evidence is lacking to support psychotropic medication use. Delusions and hallucinations are common in Alzheimer's disease, and hallucinations are common in Parkinson's disease and Lewy body dementia. Psychosis in dementia is associated with increased agitation and a poor prognosis. Although commonly used, no medications are currently approved for treating psychosis in dementia patients in the USA and nonpharmacological interventions need consideration.

CONCLUSION

The plethora of possible causes of late-onset psychosis requires accurate diagnosis, estimation of prognosis, and cautious clinical management because older adults have greater susceptibility to the adverse effects of psychotropic medications, particularly antipsychotics. Research is warranted on developing and testing efficacious and safe treatments for late-onset psychotic disorders.

Aging of persons with schizophrenia: analysis of a national dataset

OBJECTIVES

The number of older adults suffering from schizophrenia is increasing. Despite this, less than 1% of published studies about schizophrenia focus on those older than 65 years. Research indicates these individuals may age differently from the general population due to lifestyle, medication factors, and effects of the disease itself. We aimed to analyze whether schizophrenia was associated with a younger age at first assessment for social care as a proxy measure for accelerated aging.

DESIGN

We analyzed the effect of schizophrenia diagnosis, demographics, mood, comorbidities, falls, cognition, and substance use on age at first assessment for social care using linear regression.

PARTICIPANTS

We used data from 168,780 interRAI Home Care and Long-Term Care Facility (HC; LTCF) assessments completed from July 2013 to June 2020.

RESULTS

When corrected for confounding factors, schizophrenia contributed to age at first assessment being 5.5 years younger (p = 0.0001 Cohen's D = 1.0) than in people free from schizophrenia. Its effect on age at first assessment was second only to smoking. People suffering from schizophrenia also required a higher level of care (long-term care facility rather than home care). People suffering from schizophrenia had significantly higher rates of diabetes mellitus and chronic obstructive pulmonary disease but otherwise had lower rates of comorbidity than people free from schizophrenia who required care.

CONCLUSIONS

Aging with schizophrenia is associated with needing increased social care at a younger age. This has implications for social spending and developing policies to decrease frailty in this population.

Associations between age and neurocognition in individuals at clinical high risk and first-episode psychosis

Neurocognitive deficits differ with age during the early stages of psychosis. This study aimed to explore age-related differences (9-35 years old) in the neurocognitive performance of a large clinical population. In total, 1059 individuals with first-episode psychosis (FEP), 794 individuals with a clinical high risk of psychosis (CHR), and 774 well-matched healthy controls (HC) were recruited between 2016 and 2021. Neurocognitive assessments were performed using the Chinese version of the Measurement and Treatment Research to Improve Cognition in Schizophrenia Battery(MCCB). The MCCB subtest scores differed significantly among the groups across the age span. The mean scores of subtests in CHR individuals were approximately one standard deviation(SD) lower than that of HC, while that of FEP patients was approximately two SDs. The adolescents performed better than the adults in the HC, CHR, and FEP groups. In the HC group, a stronger correlation was found between age and cognitive function, and more neurocognitive domains were affected by age than in the CHR and FEP groups. These results emphasize that neurocognitive deficits in psychosis are present at the pre-onset stage and deteriorate at the first-episode stage across the age span, implicating the development of specific strategies that could monitor the cognitive trajectory in early psychosis.

Review of Major Social Determinants of Health in Schizophrenia-Spectrum Psychotic Disorders: III. Biology

BACKGROUND

Social determinants of health (SDoHs) are nonmedical factors that significantly impact health and longevity. We found no published reviews on the biology of SDoHs in schizophrenia-spectrum psychotic disorders (SSPD).

STUDY DESIGN

We present an overview of pathophysiological mechanisms and neurobiological processes plausibly involved in the effects of major SDoHs on clinical outcomes in SSPD.

STUDY RESULTS

This review of the biology of SDoHs focuses on early-life adversities, poverty, social disconnection, discrimination including racism, migration, disadvantaged neighborhoods, and food insecurity. These factors interact with psychological and biological factors to increase the risk and worsen the course and prognosis of schizophrenia. Published studies on the topic are limited by cross-sectional design, variable clinical and biomarker assessments, heterogeneous methods, and a lack of control for confounding variables. Drawing on preclinical and clinical studies, we propose a biological framework to consider the likely pathogenesis. Putative systemic pathophysiological processes include epigenetics, allostatic load, accelerated aging with inflammation (inflammaging), and the microbiome. These processes affect neural structures, brain function, neurochemistry, and neuroplasticity, impacting the development of psychosis, quality of life, cognitive impairment, physical comorbidities, and premature mortality. Our model provides a framework for research that could lead to developing specific strategies for prevention and treatment of the risk factors and biological processes, thereby improving the quality of life and increasing the longevity of people with SSPD.

CONCLUSIONS

Biology of SDoHs in SSPD is an exciting area of research that points to innovative multidisciplinary team science for improving the course and prognosis of these serious psychiatric disorders.

Self-compassion, but not compassion toward others, is associated with better physical health: A cross-sectional study

Compassion is a modifiable construct that is associated with better physical health outcomes but, to our knowledge, has seldom been studied in people with schizophrenia (PwS) despite its applicability to counteract widespread depression in this community that might prevent positive health behaviors. We hypothesized that, compared to non-psychiatric comparison subjects (NCs), PwS would have lower compassion toward self (CTS), lower compassion toward others (CTO), and a positive association between compassion and health outcomes, such as physical wellbeing, comorbidities, and plasma hs-CRP. This cross-sectional study examined differences in physical health, CTS, and CTO in 189 PwS and 166 NCs. We used general linear models to analyze the relationship between compassion and health. As hypothesized, PwS had lower levels of CTS and CTO, worse physical well-being, more comorbidities, and higher levels of plasma hs-CRP than NCs. In the combined sample, higher CTS was significantly associated with better physical well-being and fewer comorbidities, while higher CTO was significantly associated with more comorbidities. In PwS alone, higher CTS was significantly associated with better physical well-being and lower levels of hs-CRP. CTS seemed to have a larger positive association with physical health than CTO, with depression acting as a potential mediator for CTS. Exploring effects of CTS interventions on physical health and health behaviors could be a promising next step.

Subjective Overview of Accelerated Aging in Schizophrenia

Schizophrenia, like many other human diseases, particularly neuropsychiatric diseases, shows evidence of accelerated brain aging. The molecular nature of the process of aging is unknown but several potential indicators have been used in research. The concept of accelerated aging in schizophrenia took hold in 2008 and its timing, pace, determinants and deterrents have been increasingly examined since. The present overview of the field is brief and selective, based on diverse studies, expert opinions and successive reviews. Current thinking is that the timing of age acceleration in schizophrenia can occur at different time periods of the lifespan in different individuals, and that antipsychotics may be preventive. The majority opinion is that the cognitive decline and premature death often seen in schizophrenia are, in principle, preventable.

Public mental health service use among U.S. adults age 50+ compared to younger age groups

Despite increasing numbers of older-adult mental health service users, few studies have examined their use of public mental health services. Using the 2018 and 2019 Mental Health-Client Level data for clients age 18+ (N = 4,291,737 in 2018 and N = 4,513,946 in 2019), we examined whether those age 50+ who received outpatient-only, both outpatient and inpatient, or inpatient-only services had greater odds of certain types of mental disorders, especially schizophrenia, than younger adults. Of all users, 25.3% were age 50-64 and 6.7% were age 65 + . Multivariable logistic regression results, controlling for gender, race/ethnicity, census region, and alcohol/substance use disorder, showed that compared to the 30-49 age group, the 50-64 and 65+ age groups had higher odds of having depressive disorder in outpatient-only settings; however, they had consistently higher odds of a diagnosis of schizophrenia or other psychotic disorder in all three service settings. Along with advocating for increased funding for publicly-financed mental health services, social workers in public mental health service systems should ensure that they utilize effective intervention skills for older adults with serious mental illness.

National trends in metabolic risk of psychiatric inpatients in the United States during the atypical antipsychotic era

Although the cardiometabolic effects of atypical antipsychotics have been well-described in clinical samples, less is known about the longer-term impacts of these treatments. We report rates of metabolic syndrome in a nationally representative sample of U.S. adult inpatients 1993-2018 admitted for schizophrenia-spectrum disorders (n = 1,785,314), any mental health disorder (n = 8,378,773), or neither (n = 14,458,616) during a period of widespread atypical antipsychotic use. Metabolic syndrome, derived from additional diagnoses, was defined as three or more of hypertension, dyslipidemia, type II diabetes, hyperglycemia, and overweight or obese. Using an ecological age and period design, a 4-level period variable was constructed to proxy for atypical antipsychotic exposure as the minimum of age minus 20 years or the calendar year minus 1997 in accord with the disease course for schizophrenia-spectrum illness and the market share of atypical antipsychotics in the U.S. Logistic regression models, adjusted for age, year, and exposure main effects, estimated odds ratios (ORs) of metabolic syndrome. Relative to other mental health or other discharges, schizophrenia-spectrum discharges had an elevated risk for metabolic syndrome regardless of potential atypical antipsychotic exposure (OR = 1.46; 95 % CI, 1.30-1.64). For schizophrenia-spectrum discharges, periods of potential atypical antipsychotic exposure conferred additional metabolic syndrome risk OR = 1.21; 95 % CI, 1.04-1.41 for exposures of 1-2 years, OR = 1.29; 95 % CI, 1.13-1.46 for 3-7 years, OR = 1.27; 95 % CI, 1.12-1.44 for 8-12 years, and OR = 1.10; 95 % CI 0.98-1.24 for >12 years. In summary, cardiometabolic disease and related risks were elevated among a nationally representative sample of adult inpatients with schizophrenia-spectrum disorders during a period of pervasive atypical antipsychotic use.

Meaning-making processes across the lifespan: An investigation of the developmental course of metacognitive capacity

Deficits in metacognitive capacity (i.e., the ability to integrate knowledge of oneself and others into a cohesive whole) have been shown to lead to poor functional outcome in psychosis. However, there is a gap in the literature concerning the role of metacognition in typically developing populations, which makes it difficult to define what level of metacognition is normative and at what point deficits in metacognition suggest pathology. To explore this issue, we utilized cross-sectional design to assess metacognitive capacities among 69 neurotypical adults whose ages varied from 18 to 65 using the Metacognitive Assessment Scale - Abbreviated (MAS-A) and then compared those with MAS-A scores from a second previously gathered sample of 360 adults diagnosed with psychosis across four key developmental windows: emerging adulthood, early adulthood, middle adulthood, and late adulthood. Our findings suggest that in our overall sample, individuals with psychosis had significantly lower levels of metacognitive capacity across all domains assessed by the MAS-A in comparison to neurotypical individuals. Additionally, our data suggest a deleterious effect of psychosis such that individuals with psychosis showed significantly lower metacognition in each developmental stage. Additionally, these differences were largest in emerging and late adulthood and for both groups awareness of others stood out as the single metacognitive domain which was significantly less impaired among older groups. Our results suggest a developmental course for metacognitive capacity such that awareness of others is the sole domain that grows over the lifespan.

Improving Healthy Living in Residential Care Facilities: Feasibility, Acceptability, and Appropriateness of Implementing a Multicomponent Intervention for Diabetes Risk Reduction in Adults with Serious Mental Illnesses

Persons with serious mental illnesses experience high rates of medical comorbidity, especially diabetes. This study examined initial implementation feasibility, acceptability, and appropriateness of a new 6-month Multicomponent Intervention for Diabetes risk reduction in Adults with Serious mental illnesses (MIDAS) among persons in residential care facilities (RCFs). We conducted a mixed-methods study using four types of quantitative and qualitative data sources (administrative data; structured facility-level observations; resident assessments including blood-based biomarkers, 24-h dietary recalls, and self-report physical activity; and focus groups/interviews with staff and participants), to assess evidence of and factors affecting intervention feasibility, acceptability, and appropriateness. It was feasible to provide a high percentage of MIDAS class sessions (mean 50 of 52 intended sessions delivered) and make nutrition-related RCF changes (substitutions for healthier food items and reduced portion sizes). Class attendance rates and positive feedback from residents and staff provided evidence of MIDAS acceptability and appropriateness for addressing identified health needs. The residents who attended ≥ 85% of the sessions had greater improvement in several desired outcomes compared to others. Implementing a fully integrated MIDAS model with more extensive changes to facilities and more fundamental health changes among residents was more challenging. While the study found evidence to support feasibility, acceptability, and appropriateness of individual MIDAS components, some challenges for full implementation and success in obtaining immediate health benefits were also apparent. The study results highlight the need for improving health among RCF populations and will inform MIDAS adaptations designed to improve intervention fit and effectiveness outcomes.

Antipsychotic drug treatment of schizophrenia in later life: Results from the European cross-sectional AMSP study

OBJECTIVES

To investigate the relationship between patient age and the selection and dosage of antipsychotic drugs (APDs) for treatment of schizophrenia. We describe age effects for multiple individual APDs, thus allowing comparisons between drugs.

METHODS

Prescription data of 32,062 inpatients with schizophrenia from 2000 to 2017 were obtained from the Drug Safety Program in Psychiatry (AMSP) database. APD selection and dosage were related to patient age with sex as an influencing variable. Moreover, a systematic search of current guideline recommendations on APD treatment in patients with schizophrenia aged ≥65 years was performed.

RESULTS

Eighty percentof elderly patients (≥65 years) received a second-generation APD, most commonly risperidone. The dosage of APDs increased with age until about age 40 years, then decreased slowly at first and more steeply beyond age 55 years. The influence of age as well as sex on dosage partly differed between the individual drugs. Only one of eight schizophrenia guidelines systematically addressed specific aspects of pharmacotherapy in older adults.

CONCLUSIONS

In clinical routine, age has a significant impact on selection and dosing of APDs. Information on optimising pharmacotherapy in older adults with schizophrenia from clinical trials is needed. Guidelines should be improved regarding APD therapy specifically for older adults.

Shared genetic links between frontotemporal dementia and psychiatric disorders

BACKGROUND

Epidemiological and clinical studies have suggested comorbidity between frontotemporal dementia (FTD) and psychiatric disorders. FTD patients carrying specific mutations were at higher risk for some psychiatric disorders, and vice versa, implying potential shared genetic etiology, which is still less explored.

METHODS

We examined the genetic correlation using summary statistics from genome-wide association studies and analyzed their genetic enrichment leveraging the conditional false discovery rate method. Furthermore, we explored the causal association between FTD and psychiatric disorders with Mendelian randomization (MR) analysis.

RESULTS

We identified a significant genetic correlation between FTD and schizophrenia at both genetic and transcriptomic levels. Meanwhile, robust genetic enrichment was observed between FTD and schizophrenia and alcohol use disorder. Seven shared genetic loci were identified, which were mainly involved in interleukin-induced signaling, synaptic vesicle, and brain-derived neurotrophic factor signaling pathways. By integrating cis-expression quantitative trait loci analysis, we identified MAPT and CADM2 as shared risk genes. MR analysis showed mutual causation between FTD and schizophrenia with nominal association.

CONCLUSIONS

Our findings provide evidence of shared etiology between FTD and schizophrenia and indicate potential common molecular mechanisms contributing to the overlapping pathophysiological and clinical characteristics. Our results also demonstrate the essential role of autoimmunity in these diseases. These findings provide a better understanding of the pleiotropy between FTD and psychiatric disorders and have implications for therapeutic trials.

Predictors of admission to an assertive outreach service for psychosis in Lebanon

Schizophrenia is a chronic, debilitating mental illness that contributes significantly to the global burden of disease. Assertive outreach treatment for patients with schizophrenia and psychotic disorders has been implemented to improve treatment adherence and outcomes. The suitability of this model of care outside the western context has not been fully established. We describe the characteristics of 45 patients enrolled in the Psychosis Recovery Outreach Program (PROP), a program developed at a leading psychiatric facility in Lebanon. We collected twelve-month data for patients and used logistic regression models to identify predictor variables for enrollment in the service compared to those receiving standard treatment. Patients were mostly males (77.8%), younger than 39 years (80%), of college or higher education (68.2%), and diagnosed with schizophrenia (46.7%) or schizoaffective disorder (48.9%). About one-quarter (22.7%) had a comorbid cannabis use disorder. A majority received more than one oral antipsychotic (75.6%) while half (51.1%) were maintained on a long-acting injectable (LAI) antipsychotic. The following variables were significant predictors of enrollment in PROP: having a comorbid cannabis use disorder (OR 2.83 [1.25 - 6.37]), being prescribed a LAI antipsychotic (OR 9.99 [4.93-20.24]) or more than one oral antipsychotic (OR 4.57 [2.22-9.39]), visiting the emergency department more than once (OR 8.7 [2.64-28.68]), and admission to the psychiatry unit (OR 13.91 [3.17-60.94]). In addition, those following up in PROP were younger and less likely to be in the oldest age group (over 54 years) [OR 0.11 (0.01-0.93)], less likely to be females (OR 0.39 [0.18-0.81]), and less likely to be diagnosed with "other psychotic disorder" as compared to schizophrenia (OR 0.14 [0.03 - 0.62]). Our findings highlight that the assertive outreach model of care is applicable to its target population in the context of psychiatric care in Lebanon, namely young individuals with psychosis, higher comorbidities and a severe course of illness.

Frailty among inpatients with Schizophrenia: Status, influencing factors, and their correlation with quality of life

OBJECTIVE

This study aimed to understand frailty and its influencing factors in inpatients with Schizophrenia in Chengdu and to explore correlations between frailty and quality of life.

METHODS

From May to July 2022, inpatients with Schizophrenia were surveyed using a general information questionnaire, frailty phenotype (FP) scoring, the Self-Rating Depression Scale (SDS), the Mini-Mental State Examination (MMSE), and the SZ Quality of Life Scale (SQLS). Multivariate logistic regression was conducted to assess factors influencing frailty and multivariate linear regression was conducted to assess the factors influencing quality of life.

RESULTS

A total of 556 hospitalized patients with Schizophrenia were included and divided into three groups according to the degree of frailty, of which 153 cases (27.5%) were without frailty, 348 cases (62.6%) were in early frailty, and 55 cases (9.9%) were in frailty. Univariate analysis of age, history of falls during hospitalization, polypharmacy, compulsory treatment during hospitalization, self-reported health status, activity level, cognitive impairment, depressive symptoms, "psychology and society," "motivation and energy" and "symptoms and side-effects" showed statistically significant differences between the groups. Multinomial logistic regression showed that age, BMI, self-reported health, activity, cognitive impairment, motivation and energy, and symptoms and side-effects were influencing factors for frailty in hospitalized patients with Schizophrenia. Correlation analysis shows that frailty score positively correlated with SQLS score.

CONCLUSION

We found that frailty was prevalent and that frailty was positively correlated with SQLS scores in inpatients with Schizophrenia. To effectively manage the frailty of hospitalized patients with Schizophrenia, medical staff should pay attention to its influencing factors and quality of life.

Ageing with psychosis - Fifty and beyond

OBJECTIVE

While there is considerable current emphasis on youth and early psychosis, relatively little is known about the lives of people who live with psychotic disorders into middle age and beyond. We investigated social functioning, physical health status, substance use and psychiatric symptom profile in people with psychotic disorders aged between 50 and 65 years.

METHODS

Data were collected as part of the Survey of High Impact Psychosis, a population-based survey of Australians aged 18-65 years with a psychotic disorder. We compared those aged 50-65 years (N = 347) with those aged 18-49 years (N = 1478) across a range of measures.

RESULTS

The older group contained more women and more people with affective psychoses compared to the younger group. They were also more likely to have had a later onset and a chronic course of illness. The older group were more likely to have negative symptoms but less likely to exhibit positive symptoms; they also had lower current cognition, compared to the younger group. Compared to the younger group, the older group were more likely to be divorced/separated, to be living alone and to be unemployed. They had substantially lower lifetime use of alcohol and illicit substances, but rates of obesity, metabolic syndrome and diabetes mellitus were higher.

CONCLUSION

Our findings suggest that the characteristics of people with psychosis change significantly as they progress into the middle age and beyond. A better understanding of these differences is important in informing targeted treatment strategies for older people living with psychosis.

Schizophrenia and Dental Health: A Systematic Review

ABSTRACT

Schizophrenia is characterized not only by psychopathological symptoms but also by medical comorbidities. Among the latter, there are limited data on dental health. We conducted a systematic review with the primary aim of clarifying the extent of the relationship between dental diseases and schizophrenia. The second aim was to delineate an intervention program based on illness-related factors that influence dental health. The preferred reporting items for systematic reviews and meta-analyses statement for reporting systematic reviews was used. Only articles published in English language peer-reviewed journals were considered; we excluded case reports, meta-analyses, and systematic reviews, as well as studies that did not clearly report statistical analysis, diagnostic criteria, or the number of patients included. Twenty-one studies comprising 13,110 patients with schizophrenia and 9025 healthy controls were included. Negative symptomatology, long duration of illness, smoking habit, drug-induced xerostomia, and neuroinflammation are the most critical areas. We suggest an intervention program for prevention and treatment of dental diseases in schizophrenia.

Gut microbiome in serious mental illnesses: A systematic review and critical evaluation

Schizophrenia and bipolar disorder (BD) are associated with debilitating psychiatric and cognitive dysfunction, worse health outcomes, and shorter life expectancies. The pathophysiological understanding of and therapeutic resources for these neuropsychiatric disorders are still limited. Humans harbor over 1000 unique bacterial species in our gut, which have been linked to both physical and mental/cognitive health. The gut microbiome is a novel and promising avenue to understand the attributes of psychiatric diseases and, potentially, to modify them. Building upon our previous work, this systematic review evaluates the most recent evidence of the gut microbiome in clinical populations with serious mental illness (SMI). Sixteen articles that met our selection criteria were reviewed, including cross-sectional cohort studies and longitudinal treatment trials. All studies reported alterations in the gut microbiome of patients with SMI compared to non-psychiatric comparison subjects (NCs), and beta-diversity was consistently reported to be different between schizophrenia and NCs. Ruminococcaceae and Faecalibacterium were relatively decreased in BD, and abundance of Ruminococcaceae was reported across several investigations of SMI to be associated with better clinical characteristics. Lactic acid bacteria were relatively more abundant in SMI and associated with worse clinical outcomes. There was very limited evidence for the efficacy of probiotic or prebiotic interventions in SMI. As microbiome research in psychiatry is still nascent, the extant literature has several limitations. We critically evaluate the current data, including experimental approaches. There is a need for more unified methodological standards in order to arrive at robust biological understanding of microbial contributions to SMI.

Cognitive discrepancies, motivation and subjective well-being in people with schizophrenia

Research indicates that people with schizophrenia often achieve similar levels of subjective well-being (SWB) compared to healthy controls despite prominent symptomatology and significant functional difficulties. Furthermore, compared to healthy controls, young-adult people with schizophrenia differ in the relative importance they place on values, or guiding life principles, associated with educational and occupational success (openness to change), suggesting that changing motivations may contribute to SWB and the apparent motivational deficits commonly reported in this population. The current study sought to better understand these relationships in middle-aged people with schizophrenia or schizoaffective disorder (n=29) versus a relatively healthy group of community controls (n=23). Participants completed measures of SWB and values. They also completed a cognitive battery and interviews concerned with mental and physical health. Patients reported similar levels of SWB compared to controls in the context of significant cognitive, social and vocational difficulties. Moreover, living consistently with values (valued living) predicted SWB in both groups. Lastly, internalized mental illness stigma was negatively associated with openness to change in the patient group. While encouraging from an emotional resiliency perspective, SWB and valued living in people with schizophrenia may hinder motivation towards treatment goals that could otherwise improve functional outcomes in this population.

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Patients with schizophrenia reported similar levels of SWB compared to community controls.

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Living consistently with values (i.e., valued living) predicted SWB in both groups.

•

Internalized mental illness stigma was negatively associated with openness to change values in the patient group.

•

Changing motivations may contribute to the apparent motivational deficits commonly reported in people with schizophrenia.

"Moving forward despite adversity": The lives of Korean older adults with schizophrenia

INTRODUCTION

Older adults with schizophrenia experience aging-related challenges and chronic psychiatric difficulties. However, their uniqueness is understudied. Aim This study explored three life stories to illuminate schizophrenia's trajectory.

METHOD

A narrative inquiry method was used to elicit rich narratives in chronic patients' lives. Two men and one woman suffering from chronic schizophrenia for more than 20 years were engaged in conversation three times.

RESULTS

The analysis revealed one main theme expressing their fundamental perspective on their lives: "moving forward despite adversity." Three subthemes emerged: living with the mental disorder, giving and receiving support, and adaptation to old age. They reflected on their interpersonal relationships, failures, and successes in the context of the challenges of schizophrenia. They indicated adapting to schizophrenia, exchanging social support with loved ones, and meeting aging-related challenges with confidence. They were hopeful about brighter personal futures than their pasts.

DISCUSSION

Family and community supports were very important; self-acceptance positively influenced their successful community living.

IMPLICATIONS FOR PRACTICE

For effective long-term treatment of older adults with schizophrenia, mental health policies should focus on meeting the social needs of patients and families and reorient programs away from the medical model limited to symptom reduction.

Disentangling age- and disease-related alterations in schizophrenia brain network using structural equation modeling: A graph theoretical study based on minimum spanning tree

Functional brain networks have been shown to undergo fundamental changes associated with aging or schizophrenia. However, the mechanism of how these factors exert influences jointly or interactively on brain networks remains elusive. A unified recognition of connectomic alteration patterns was also hampered by heterogeneities in network construction and thresholding methods. Recently, an unbiased network representation method regardless of network thresholding, so called minimal spanning tree algorithm, has been applied to study the critical skeleton of the brain network. In this study, we aimed to use minimum spanning tree (MST) as an unbiased network reconstruction and employed structural equation modeling (SEM) to unravel intertwined relationships among multiple phenotypic and connectomic variables in schizophrenia. First, we examined global and local brain network properties in 40 healthy subjects and 40 schizophrenic patients aged 21–55 using resting‐state functional magnetic resonance imaging (rs‐fMRI). Global network alterations are measured by graph theoretical metrics of MSTs and a connectivity‐transitivity two‐dimensional approach was proposed to characterize nodal roles. We found that networks of schizophrenic patients exhibited a more star‐like global structure compared to controls, indicating excessive integration, and a loss of regional transitivity in the dorsal frontal cortex (corrected p <.05). Regional analysis of MST network topology revealed that schizophrenia patients had more network hubs in frontal regions, which may be linked to the “overloading” hypothesis. Furthermore, using SEM, we found that the level of MST integration mediated the influence of age on negative symptom severity (indirect effect 95% CI [0.026, 0.449]). These findings highlighted an altered network skeleton in schizophrenia and suggested that aging‐related enhancement of network integration may undermine functional specialization of distinct neural systems and result in aggravated schizophrenic symptoms.

Ageing with schizophrenia: an update

PURPOSE OF REVIEW

The aim of this review was to summarize the recent literature on the clinical symptoms, functioning, outcomes and treatments for older adults with chronic schizophrenia.

RECENT FINDINGS

The number and proportion of older adults with schizophrenia is rapidly increasing. Schizophrenia is a heterogeneous disorder and older adults with schizophrenia display significant variability in symptom severity, quality of life and overall outcomes. Many achieve stable disease remission, some display persistent nonremission and others experience fluctuating symptoms. Depression is commonly reported, and although rates of suicide are higher when compared with age-matched peers, the excess mortality seen in this population is mainly attributed to natural causes of death. Cognitive decline and reduced illness awareness have important implications for functional status and quality of life. Antipsychotics remain essential in the treatment regimen, although elderly patients with chronic disease may be good candidates for gradual dose reduction. Interdisciplinary treatment approaches as well as nonpharmacologic psychosocial interventions play a critical adjunctive role in the treatment of older adults with schizophrenia.

SUMMARY

Research focusing on schizophrenia in late life is sparse. Too often, older patients are eliminated from research studies or averaged in with all age groups. Thus, there continues to be gaps in our understanding of modifiable predictors of remission and recovery, and the most efficacious and safest treatment approaches for this age group.

[Accelerated telomere erosion in schizophrenia: A literature review]

Schizophrenia is associated with a weighted average of 14.5 years of potential life lost according to a recent meta-analysis. This is partly explained by high rates of suicide and a high prevalence of non-psychiatric comorbidity (cardiovascular diseases, diabetes, cancers…). However, all these causes could not fully explain the loss of life expectancy in people suffering from schizophrenia. Life expectancy has been strongly correlated with telomere length (TL). Telomeres are noncoding structures consisting of DNA TTAGGG tandem repeats and associated proteins located at the end of the chromosomes. Their role is to help preserve genome stability by protecting chromosomal ends from the loss of genetic material. The progressive loss of telomeric material during cell divisions has led researchers to consider telomeres as molecular clocks that measure the number of divisions left until cellular death. The fact that both shorter telomeres and schizophrenia have been associated with a decrease in life expectancy has fueled the interest in the study of TL in schizophrenia. In this article, after a detailed review of the literature on the relationships between telomere length and schizophrenia, we discuss the different pathophysiological mechanisms which might explain this association. Based on this analysis, in the last part of the article we discuss potential research, therapeutic and prevention prospects. To date, the majority of the studies and meta-analyses found a decrease in TL in subjects with schizophrenia compared to control subjects. Conversely, all the studies exploring the TL in subjects suffering from first episode psychosis (FEP) have shown no significant difference from TL in control subjects. This suggests that excessive shortening of telomeres occurs during the course of the disease, thus it seems more probable that schizophrenia (or processes associated with it) affects TL rather than telomere erosion being a cause of the disorder. Several pathophysiological, non-mutually exclusive mechanisms have been proposed to explain the observed data. A first hypothesis to explain the acceleration of the physiological process of telomere erosion in schizophrenia is the activation of inflammation processes and oxidative stress as a consequence of schizophrenia per se. However, it seems more probable that reduced TL may be a result of cumulative exposure to chronic stress related to schizophrenia. Indeed, in healthy individuals a growing body of evidence has linked chronic stress to accelerated shortening of TL. This might explain why telomere erosion is too small to be detected in FEP patients who are younger and have a shorter duration of illness than subjects with schizophrenia. Based on these both explanations, telomere alterations may be considered as a biomarker of illness progression and might be useful for illness staging. Identifying processes associated with TL reduction might improve our understanding of the increased mortality and morbidity in schizophrenia, improve reliability of diagnosis, and hopefully suggest means for prevention and/or treatment. Treatments that prevent exposure and/or vulnerability to stressful life events that ameliorate schizophrenia may also prevent or decelerate telomere erosion. In this perspective, engaging subjects suffering from schizophrenia in a healthy diet and regular activity could be both promising strategies to protect telomere maintenance and improve health span at old age. In addition, the inflammatory process and oxidative stress involved in the physiopathology in at least a subgroup of subjects with schizophrenia could also be responsible for telomere erosion. Thus, an efficient anti-inflammatory therapeutic approach that targets these specific pathways could be of interest in this subgroup to limit telomere erosion. Mindfulness-based stress reduction (MBSR) therapies have been shown to reduce telomere erosion by increasing telomerase activity, although these psychological therapies should be used carefully in psychosis. Finally, advancing our understanding of the relationship between stress, inflammation and TL is of great interest for psychiatric research and for understanding stress effects in this population.

White matter brain aging in relationship to schizophrenia and its cognitive deficit

We hypothesized that cerebral white matter deficits in schizophrenia (SZ) are driven in part by accelerated white matter aging and are associated with cognitive deficits. We used a machine learning model to predict individual age from diffusion tensor imaging features and calculated the delta age (Δage) as the difference between predicted and chronological age. Through this approach, we translated multivariate white matter imaging features into an age-scaled metric and used it to test the temporal trends of accelerated aging-related white matter deficit in SZ and its association with the cognition. A feature selection procedure was first employed to choose fractional anisotropy values in 34 of 43 white fiber tracts. Using these features, a machine learning model was trained based on a training set consisted of 107 healthy controls (HC). The brain age of 166 SZs and 107 HCs in the testing set were calculated using this model. Then, we examined the SZ-HC group effect on Δage and whether this effect was moderated by chronological age using the regression spline model. The results showed that Δage was significantly elevated in the age > 30 group in patients (p < 0.001) but not in age ≤ 30 group (p = 0.364). Δage in patients was significantly and negatively associated with both working memory (β = -0.176, p = 0.007) and processing speed (β = -0.519, p = 0.035) while adjusting sex and chronological age. Overall, these findings indicate that the Δage is elevated in SZs and become significantly from the third decade of life; the increase of Δage in SZs is associated with the declined neurocognitive performance.

Biological aging in schizophrenia and psychosis severity: DNA methylation analysis

The physiological changes associated with normal aging are known to occur earlier in individuals with schizophrenia (SCZ). One of the phenomena linked with normal aging is the change in patterns of epigenetic modifications. We recruited 138 individuals with SCZ spectrum disorders and extracted DNA from white blood cells. The combinations of pre-selected DNA methylation sites were utilized to estimate the 'methylation age' (DNAm age) and evaluate evidence of epigenetic age acceleration. We investigated the correlation between the epigenetic age acceleration measures and psychosis severity; furthermore, we estimated blood cell counts based on DNA methylation levels. The extrinsic epigenetic age acceleration showed a significant correlation with the Brief Psychiatric Rating Scale (BPRS) disorganization subscale(r=0.222, p=0.039).Both Horvath age acceleration and Hannum age acceleration showed a significant correlation (r=0.221, p=0.029; r=0.242, p=0.017 respectively) with the Symptom Checklist 90 (SCL-90) psychotic domain. Overall, this study shows some evidence of epigenetic age acceleration associated with psychosis severity using two different algorithms for DNAm age analysis.

A White Matter Connection of Schizophrenia and Alzheimer's Disease

Schizophrenia (SZ) is a severe psychiatric illness associated with an elevated risk for developing Alzheimer's disease (AD). Both SZ and AD have white matter abnormalities and cognitive deficits as core disease features. We hypothesized that aging in SZ patients may be associated with the development of cerebral white matter deficit patterns similar to those observed in AD. We identified and replicated aging-related increases in the similarity between white matter deficit patterns in patients with SZ and AD. The white matter "regional vulnerability index" (RVI) for AD was significantly higher in SZ patients compared with healthy controls in both the independent discovery (Cohen's d = 0.44, P = 1·10-5, N = 173 patients/230 control) and replication (Cohen's d = 0.78, P = 9·10-7, N = 122 patients/64 controls) samples. The degree of overlap with the AD deficit pattern was significantly correlated with age in patients (r = .21 and .29, P < .01 in discovery and replication cohorts, respectively) but not in controls. Elevated RVI-AD was significantly associated with cognitive measures in both SZ and AD. Disease and cognitive specificities were also tested in patients with mild cognitive impairment and showed intermediate overlap. SZ and AD have diverse etiologies and clinical courses; our findings suggest that white matter deficits may represent a key intersecting point for these 2 otherwise distinct diseases. Identifying mechanisms underlying this white matter deficit pattern may yield preventative and treatment targets for cognitive deficits in both SZ and AD patients.

Gut microbiome in Schizophrenia: Altered functional pathways related to immune modulation and atherosclerotic risk

Emerging evidence has linked the gut microbiome changes to schizophrenia. However, there has been limited research into the functional pathways by which the gut microbiota contributes to the phenotype of persons with chronic schizophrenia. We characterized the composition and functional potential of the gut microbiota in 48 individuals with chronic schizophrenia and 48 matched (sequencing plate, age, sex, BMI, and antibiotic use) non-psychiatric comparison subjects (NCs) using 16S rRNA sequencing. Patients with schizophrenia demonstrated significant beta-diversity differences in microbial composition and predicted genetic functional potential compared to NCs. Alpha-diversity of taxa and functional pathways were not different between groups. Random forests analyses revealed that the microbiome predicts differentiation of patients with schizophrenia from NCs using taxa (75% accuracy) and functional profiles (67% accuracy for KEGG orthologs, 70% for MetaCyc pathways). We utilized a new compositionally-aware method incorporating reference frames to identify differentially abundant microbes and pathways, which revealed that Lachnospiraceae is associated with schizophrenia. Functional pathways related to trimethylamine-N-oxide reductase and Kdo2-lipid A biosynthesis were altered in schizophrenia. These metabolic pathways were associated with inflammatory cytokines and risk for coronary heart disease in schizophrenia. Findings suggest potential mechanisms by which the microbiota may impact the pathophysiology of the disease through modulation of functional pathways related to immune signaling/response and lipid and glucose regulation to be further investigated in future studies.

Predicting rehospitalisation in older inpatients with a psychotic disorder

OBJECTIVE

The objective of this study was to predict rehospitalisation in a psychiatric clinic in older inpatients with a psychotic disorder.

METHODS/DESIGN

In this prospective, observational study, all eligible inpatients aged 55 years and over with a primary psychotic disorder, admitted to a specialised ward for older psychotic patients in a large psychiatric inpatient clinic in the Netherlands, were asked to participate. Whether or not patients were rehospitalised and time to rehospitalisation were assessed 1 year after discharge from the ward. We recorded age, gender, living arrangement, psychiatric diagnosis, severity of psychotic symptoms, duration of index episode, age of onset of psychotic disorder, number of previous admissions, involuntary admission and use of depot medication at discharge. All patients underwent a neuropsychological assessment.

RESULTS

Of the 90 patients that were included, 32 (35.6%) had been readmitted within 1 year after discharge. None of the demographic or clinical variables predicted rehospitalisation or the time to rehospitalisation.

CONCLUSION

Factors that predict rehospitalisationin younger adult patients with schizophrenia may not predict rehospitalisationin older patients with a psychotic disorder, of which the majority suffered from schizophrenia. We expect that other factors than those investigated may be of greater importance to predict rehospitalisation, as for example social support and coping mechanisms.

Physical Functional Limitations in a First-Admission Cohort at Midlife: Findings From the Suffolk County Mental Health Project

BACKGROUND

Psychosis is a risk factor for aging-related conditions and early mortality. Little is known about the age-specific risk of objectively measured physical functional limitations among individuals with serious mental illness.

METHODS

The Suffolk County Mental Health Project is a prospective study of individuals hospitalized for the first time for psychosis. To assess physical functioning at midlife and to identify emerging risk factors for older-age changes, 101 participants with schizophrenia (mean age = 47.2, SD = 8.0 years; 41.6% female) and 112 participants with other psychoses (mean age = 48.2, SD = 9.5 years; 45.5% female) were assessed for chair-rise and balance limitations 20 years after diagnosis. A never-psychotic comparison group of 237 age/sex/geographically matched community controls was similarly assessed (mean age = 50.3, SD = 8.8 years; 44.7% female). Logistic regression was used to examine group differences in prevalence of poor performance and demographic, medical, and treatment correlates.

RESULTS

Chair-rise limitations (45.5% [35.8-55.3]) and balance limitations (17.2% [9.8-24.5]) were common in individuals with schizophrenia. Prevalence of chair-rise limitations was higher in schizophrenia (46.3%) than in other psychotic disorders (31.9%) and never-psychotic group (22.1%), whereas risk of balance limitations was higher in schizophrenia (17.2%) compared with never-psychotic controls (8.1%). Schizophrenia was a significant risk factor for chair-rise (adjusted odds ratio = 3.01 [1.79-5.08], p < .001) and balance limitations (adjusted odds ratio = 2.63, [1.25-5.51], p = .010). Multivariable analysis of symptom severity found avolition was associated with chair-rise limitations, but not balance, independent of diagnosis.

CONCLUSION

Physical limitations are crucial because they identify existing problems with mobility and portend an increased risk of disability and death. Because participants with schizophrenia were at increased risk of physical limitations, assessments of chair-rise and balance limitations may be critical to monitoring individuals with psychosis.

Translating ENIGMA schizophrenia findings using the regional vulnerability index: Association with cognition, symptoms, and disease trajectory

Patients with schizophrenia have patterns of brain deficits including reduced cortical thickness, subcortical gray matter volumes, and cerebral white matter integrity. We proposed the regional vulnerability index (RVI) to translate the results of Enhancing Neuro Imaging Genetics Meta-Analysis studies to the individual level. We calculated RVIs for cortical, subcortical, and white matter measurements and a multimodality RVI. We evaluated RVI as a measure sensitive to schizophrenia-specific neuroanatomical deficits and symptoms and studied the timeline of deficit formations in: early (≤5 years since diagnosis, N = 45, age = 28.8 ± 8.5); intermediate (6-20 years, N = 30, age 43.3 ± 8.6); and chronic (21+ years, N = 44, age = 52.5 ± 5.2) patients and healthy controls (N = 76, age = 38.6 ± 12.4). All RVIs were significantly elevated in patients compared to controls, with the multimodal RVI showing the largest effect size, followed by cortical, white matter and subcortical RVIs (d = 1.57, 1.23, 1.09, and 0.61, all p < 10^-6 ). Multimodal RVI was significantly correlated with multiple cognitive variables including measures of visual learning, working memory and the total score of the MATRICS consensus cognitive battery, and with negative symptoms. The multimodality and white matter RVIs were significantly elevated in the intermediate and chronic versus early diagnosis group, consistent with ongoing progression. Cortical RVI was stable in the three disease-duration groups, suggesting neurodevelopmental origins of cortical deficits. In summary, neuroanatomical deficits in schizophrenia affect the entire brain; the heterochronicity of their appearance indicates both the neurodevelopmental and progressive nature of this illness. These deficit patterns may be useful for early diagnosis and as quantitative targets for more effective treatment strategies aiming to alter these neuroanatomical deficit patterns.

Mechanisms linking childhood trauma exposure and psychopathology: a transdiagnostic model of risk and resilience

BACKGROUND

Transdiagnostic processes confer risk for multiple types of psychopathology and explain the co-occurrence of different disorders. For this reason, transdiagnostic processes provide ideal targets for early intervention and treatment. Childhood trauma exposure is associated with elevated risk for virtually all commonly occurring forms of psychopathology. We articulate a transdiagnostic model of the developmental mechanisms that explain the strong links between childhood trauma and psychopathology as well as protective factors that promote resilience against multiple forms of psychopathology.

MAIN BODY

We present a model of transdiagnostic mechanisms spanning three broad domains: social information processing, emotional processing, and accelerated biological aging. Changes in social information processing that prioritize threat-related information-such as heightened perceptual sensitivity to threat, misclassification of negative and neutral emotions as anger, and attention biases towards threat-related cues-have been consistently observed in children who have experienced trauma. Patterns of emotional processing common in children exposed to trauma include elevated emotional reactivity to threat-related stimuli, low emotional awareness, and difficulties with emotional learning and emotion regulation. More recently, a pattern of accelerated aging across multiple biological metrics, including pubertal development and cellular aging, has been found in trauma-exposed children. Although these changes in social information processing, emotional responding, and the pace of biological aging reflect developmental adaptations that may promote safety and provide other benefits for children raised in dangerous environments, they have been consistently associated with the emergence of multiple forms of internalizing and externalizing psychopathology and explain the link between childhood trauma exposure and transdiagnostic psychopathology. Children with higher levels of social support, particularly from caregivers, are less likely to develop psychopathology following trauma exposure. Caregiver buffering of threat-related processing may be one mechanism explaining this protective effect.

CONCLUSION

Childhood trauma exposure is a powerful transdiagnostic risk factor associated with elevated risk for multiple forms of psychopathology across development. Changes in threat-related social and emotional processing and accelerated biological aging serve as transdiagnostic mechanisms linking childhood trauma with psychopathology. These transdiagnostic mechanisms represent critical targets for early interventions aimed at preventing the emergence of psychopathology in children who have experienced trauma.

Long-term Changes in Cognitive Functioning in Individuals With Psychotic Disorders: Findings From the Suffolk County Mental Health Project

IMPORTANCE

It remains uncertain whether people with psychotic disorders experience progressive cognitive decline or normal cognitive aging after first hospitalization. This information is essential for prognostication in clinical settings, deployment of cognitive remediation, and public health policy.

OBJECTIVE

To examine long-term cognitive changes in individuals with psychotic disorders and to compare age-related differences in cognitive performance between people with psychotic disorders and matched control individuals (ie, individuals who had never had psychotic disorders).

DESIGN, SETTING, AND PARTICIPANTS

The Suffolk County Mental Health Project is an inception cohort study of first-admission patients with psychosis. Cognitive functioning was assessed 2 and 20 years later. Patients were recruited from the 12 inpatient facilities of Suffolk County, New York. At year 20, the control group was recruited by random digit dialing and matched to the clinical cohort on zip code and demographics. Data were collected between September 1991 and July 2015. Analysis began January 2016.

MAIN OUTCOMES AND MEASURES

Change in cognitive functioning in 6 domains: verbal knowledge (Wechsler Adult Intelligence Scale-Revised vocabulary test), verbal declarative memory (Verbal Paired Associates test I and II), visual declarative memory (Visual Reproduction test I and II), attention and processing speed (Symbol Digit Modalities Test-written and oral; Trail Making Test [TMT]-A), abstraction-executive function (Trenerry Stroop Color Word Test; TMT-B), and verbal fluency (Controlled Oral Word Association Test).

RESULTS

A total of 705 participants were included in the analyses (mean [SD] age at year 20, 49.4 [10.1] years): 445 individuals (63.1%) had psychotic disorders (211 with schizophrenia spectrum [138 (65%) male]; 164 with affective psychoses [76 (46%) male]; 70 with other psychoses [43 (61%) male]); and 260 individuals (36.9%) in the control group (50.5 [9.0] years; 134 [51.5%] male). Cognition in individuals with a psychotic disorder declined on all but 2 tests (average decline: d = 0.31; range, 0.17-0.54; all P < .001). Cognitive declines were associated with worsening vocational functioning (Visual Reproduction test II: r = 0.20; Symbol Digit Modalities Test-written: r = 0.25; Stroop: r = 0.24; P < .009) and worsening negative symptoms (avolition: Symbol Digit Modalities Test-written: r = -0.24; TMT-A: r = -0.21; Stroop: r = -0.21; all P < .009; inexpressivity: Stroop: r = -0.22; P < .009). Compared with control individuals, people with psychotic disrders showed age-dependent deficits in verbal knowledge, fluency, and abstraction-executive function (vocabulary: β = -0.32; Controlled Oral Word Association Test: β = -0.32; TMT-B: β = 0.23; all P < .05), with the largest gap among participants 50 years or older.

CONCLUSIONS AND RELEVANCE

In individuals with psychotic disorders, most cognitive functions declined over 2 decades after first hospitalization. Observed declines were clinically significant. Some declines were larger than expected due to normal aging, suggesting that cognitive aging in some domains may be accelerated in this population. If confirmed, these findings would highlight cognition as an important target for research and treatment during later phases of psychotic illness.

Clozapine response trajectories and predictors of non-response in treatment-resistant schizophrenia: a chart review study

Although clozapine is the main antipsychotic medication for treatment-resistant schizophrenia, 40-70% of patients on clozapine have persistent psychotic symptoms (i.e. ultra-treatment-resistant schizophrenia, UTRS). We aimed to examine clozapine response/non-response patterns in patients with treatment-resistant schizophrenia, as well as determine patient clinico-demographic factors associated with long-term clozapine non-response. Clinico-demographic characteristics of 241 patients on clozapine were collected through a retrospective chart review. The median (interquartile range, IQR) follow-up from illness onset was 25.0 (IQR = 24.0) years. Clozapine response was assessed at median 10.8 (IQR = 14.0) months (Time 1, T1) and 7.2 (IQR = 13.5) years (Time 2, T2) after its initiation. It was evaluated by chart reviewers based on the information provided in clinical notes. Binomial logistic regression was used to determine clinico-demographic factors associated with clozapine non-response at both T1 and T2 (i.e. stable UTRS, S-UTRS) compared to clozapine response at both times (i.e. stable clozapine responders, S-ClozResp). Among clozapine responders (n = 122) at T1, 83.6% remained clozapine responsive and 16.4% became non-responsive at T2. In the UTRS group (n = 119) at T1, 87.4% remained clozapine non-responsive and 12.6% became responsive at T2. Duration of delay in clozapine initiation (OR = 0.94, Wald χ² = 5.33, p = 0.021) and number of pre-clozapine hospitalizations (OR = 0.95, Wald χ² = 5.20, p = 0.023) were associated with S-UTRS. Most UTRS patients were non-responsive to clozapine from the start of treatment. Preventing delay in initiating clozapine and relapses could help promote long-term clozapine response in patients with treatment-resistant schizophrenia. Future longitudinal studies are required to explore the neuropathological correlates of relapses and delay in clozapine initiation.

Executive functions in schizophrenia aging: Differential effects of age within specific executive functions

There are common cognitive and brain abnormalities in schizophrenia and healthy aging which may cumulate in schizophrenia aging. However, the course of executive deficits in late-life schizophrenia is still controversial as it remains unclear whether schizophrenia patients show accelerated aging. The use of specific models of executive functions might help to shed new lights on this issue. The aim of this study was then to determine how each of the four specific executive functions (shifting, updating, inhibition and access to long-term memory) is affected by aging in schizophrenia compared to healthy aging. 20 younger (age 18-34), 17 middle-aged (age 35-49) and 25 older (age 59-76) schizophrenia patients and 62 healthy comparison participants matched for gender, age and education performed a neurocognitive battery evaluating the four specific executive functions. Schizophrenia patients performed worse than comparison participants on shifting, updating and access, whereas inhibition appeared preserved. Age affected the four functions with increased degradation of shifting and access in schizophrenia patients, whereas updating and inhibition showed a normal decline with age. These results suggest a vulnerability of prefrontal and cingulate cortexes in schizophrenia aging. Moreover, as age affected the specific executive functions differently, remediation programs should be adapted to older patients. Models of specific executive functions are useful for understanding the complexity of cognition in schizophrenia and its course during later life so that healthcare can be adapted accordingly.

Suicide ideation, suicide attempts, their sociodemographic and clinical associates among the elderly Chinese patients with schizophrenia spectrum disorders

BACKGROUND

It is still unknown whether many well-identified risk factors of suicide could be applied to the elderly Chinese patients with schizophrenia.

METHODS

1-month suicidal ideation and lifetime suicide attempts together with their sociodemographic and clinical associates were analyzed by retrospective data on 263 elderly patients with schizophrenia spectrum disorders at the Kangning Hospital, Shenzhen, China. T-tests and Chi-square tests were used to examine the differences between patients with and without suicidality. Backward stepwise logistic regression was performed to identify the associated factors.

RESULTS

Among the selected patients, 17.87% had 1-month suicide ideation and 7.60% had lifetime suicide attempts. It was further observed that the elderly patients with schizophrenia who had 1-month suicide ideation were more likely to report lifetime suicide attempts, suffer from severe hopelessness and negative symptoms, and have no pension. However, the backward stepwise logistic regression analyses revealed that lifetime suicide attempts and negative symptoms were most significantly associated with 1-month suicide ideation. In contrast, lifetime suicide attempters were more likely to be men, receive a pension, display symptoms of hopelessness, have longer duration of illness and poor family relationships. The regression analyses also indicated that only hopelessness, relatively long duration of schizophrenia, and poor family relationships were the most significantly associated with lifetime suicide attempts.

LIMITATIONS

The retrospective design do not allow for causal inferences.

CONCLUSIONS

Early interventions designed to decrease hopelessness, control negative symptoms, and improve family relationships may result in reduced risks of suicide among elderly Chinese patients with schizophrenia.

Childhood Adversity and Schizophrenia: The Protective Role of Resilience in Mental and Physical Health and Metabolic Markers

OBJECTIVE

To determine the impact of childhood adversity and current (adulthood) resilience on mental and physical health and markers of metabolic function among adults with schizophrenia and nonpsychiatric comparison participants (NCs).

METHODS

We conducted a cross-sectional study of 114 participants with schizophrenia (DSM-IV-TR criteria) and 101 NCs aged 26-65 years during 2012-2017. Sociodemographic, clinical, and laboratory measures were examined. Childhood Trauma Questionnaire was used to retrospectively assess emotional abuse/neglect, physical abuse/neglect, and sexual abuse experienced during childhood. Connor-Davidson Resilience Scale was employed to measure resilience.

RESULTS

Persons with schizophrenia reported more severe childhood trauma, lower resilience, and worse mental and physical health and had worse metabolic biomarker levels than NCs. Trauma severity correlated with worse depression in the NCs (r = 0.34), but not in the schizophrenia group (r = 0.02). In both groups, trauma severity was associated with worse physical well-being, higher fasting insulin levels, and greater insulin resistance (P ≤ .02). Notably, resilience appeared to counteract effects of trauma and diagnosis on mental and physical health. The schizophrenia subgroup with high resilience and severe trauma reported mental and physical well-being and had glycosylated hemoglobin levels and insulin resistance scores that were comparable to those of NCs with low resilience and severe trauma.

CONCLUSIONS

To our knowledge, this is the first study to quantitatively assess effects of both childhood trauma and resilience in schizophrenia on health, notably metabolic function. Interventions to bolster resilience in the general population and in people with schizophrenia may improve outcomes for those with a history of childhood adversity.

Promoting Personal and Social Recovery in Older Persons with Schizophrenia: The Case of The New Club, a Novel Dutch Facility Offering Social Contact and Activities

Many older community-living persons with schizophrenia report unmet psychological and social needs. The Amsterdam-based New Club is a novel facility that intends to foster self-reliance and social participation in this group. To explore participants' and staff perceptions, a naturalistic qualitative study combined participant observation with interviews. The results illustrate how the New Club contributes to the personal and social recovery of its participants. At the personal level, attending the facility, activation and feeling accepted were valued positively. At the social level, engaging with others, experiencing a sense of community, and learning from one another's social skills were positive contributors. Next, various environmental factors proved important. The New Club demonstrates the feasibility of creating a facility that offers an accepting and non-demanding social environment to older community-living individuals with severe mental illnesses. It may offer a suitable alternative for the more demanding psychotherapeutic interventions offered to younger populations.

Course and predictors of symptomatic remission in late-life schizophrenia: A 5-year follow-up study in a Dutch psychiatric catchment area

BACKGROUND

The number of older schizophrenia patients is growing, the majority being treated in outpatient settings. Reported symptomatic remission rates in younger cohorts vary largely. Further insight into course trajectories and putative predictors of remission in older persons with schizophrenia is needed.

METHODS

5-year follow-up course trajectories of symptomatic remission were examined in a catchment area-based group of 77 older Dutch patients (mean age 66.0 years) with schizophrenia or schizoaffective disorder. A modified version of the 'Remission in Schizophrenia Working Group' criteria was used to determine remission status. In individuals who did not fulfil remission criteria at baseline (n = 56), predictors of conversion to remission status at 5-year follow-up were analysed using multivariable regression analyses.

RESULTS

A substantial increase in remission rate at 5-year follow-up (27.3% at baseline (T1), 49.4% at follow-up (T2)) was found. Of all participants, 23.4% was in remission at both assessments and 46.8% was in non-remission at both assessments. 26.0% of the participants converted from non-remission at T1 to remission at T2, while 3.9% fell back from remission at T1 to non-remission at T2. Two significant baseline predictors of conversion to remission at follow-up were found: lower score on the PANSS positive symptom subscale, and having a partner.

CONCLUSION

Symptomatic remission was as an attainable goal for almost half of all older patients with schizophrenia or schizoaffective disorder at 5-year follow-up. With a lower PANSS positive symptom subscale score, and having a partner emerging as the only predictors of conversion to remission, there remains a need to search for modifiable predictors.