Depression, parkinsonian symptoms, and negative symptoms in schizophrenics treated with neuroleptics

Dopamine signaling enriched striatal gene set predicts striatal dopamine synthesis and physiological activity in vivo

The polygenic architecture of schizophrenia implicates several molecular pathways involved in synaptic function. However, it is unclear how polygenic risk funnels through these pathways to translate into syndromic illness. Using tensor decomposition, we analyze gene co-expression in the caudate nucleus, hippocampus, and dorsolateral prefrontal cortex of post-mortem brain samples from 358 individuals. We identify a set of genes predominantly expressed in the caudate nucleus and associated with both clinical state and genetic risk for schizophrenia that shows dopaminergic selectivity. A higher polygenic risk score for schizophrenia parsed by this set of genes predicts greater dopamine synthesis in the striatum and greater striatal activation during reward anticipation. These results translate dopamine-linked genetic risk variation into in vivo neurochemical and hemodynamic phenotypes in the striatum that have long been implicated in the pathophysiology of schizophrenia.

Dopamine and schizophrenia from bench to bedside: Discovery of a striatal co-expression risk gene set that predicts in vivo measures of striatal function

Schizophrenia (SCZ) is characterized by a polygenic risk architecture implicating diverse molecular pathways important for synaptic function. However, how polygenic risk funnels through these pathways to translate into syndromic illness is unanswered. To evaluate biologically meaningful pathways of risk, we used tensor decomposition to characterize gene co-expression in post-mortem brain (of neurotypicals: N=154; patients with SCZ: N=84; and GTEX samples N=120) from caudate nucleus (CN), hippocampus (HP), and dorsolateral prefrontal cortex (DLPFC). We identified a CN-predominant gene set showing dopaminergic selectivity that was enriched for genes associated with clinical state and for genes associated with SCZ risk. Parsing polygenic risk score for SCZ based on this specific gene set (parsed-PRS), we found that greater pathway-specific SCZ risk predicted greater in vivo striatal dopamine synthesis capacity measured by [ 18 F]-FDOPA PET in three independent cohorts of neurotypicals and patients (total N=235) and greater fMRI striatal activation during reward anticipation in two additional independent neurotypical cohorts (total N=141). These results reveal a 'bench to bedside' translation of dopamine-linked genetic risk variation in driving in vivo striatal neurochemical and hemodynamic phenotypes that have long been implicated in the pathophysiology of SCZ.

Genetic Predisposition to Schizophrenia and Depressive Disorder Comorbidity

Background: Patients with schizophrenia have an increased risk of depressive disorders compared to the general population. The comorbidity between schizophrenia and depression suggests a potential coincidence of the pathophysiology and/or genetic predictors of these mental disorders. The aim of this study was to review the potential genetic predictors of schizophrenia and depression comorbidity. Materials and Methods: We carried out research and analysis of publications in the databases PubMed, Springer, Wiley Online Library, Taylor & Francis Online, Science Direct, and eLIBRARY.RU using keywords and their combinations. The search depth was the last 10 years (2010–2020). Full-text original articles, reviews, meta-analyses, and clinical observations were analyzed. A total of 459 articles were found, of which 45 articles corresponding to the purpose of this study were analyzed in this topic review. Results: Overlap in the symptoms and genetic predictors between these disorders suggests that a common etiological mechanism may underlie the presentation of comorbid depression in schizophrenia. The molecular mechanisms linking schizophrenia and depression are polygenic. The most studied candidate genes are GRIN1, GPM6A, SEPTIN4, TPH1, TPH2, CACNA1C, CACNB2, and BCL9.Conclusion: Planning and conducting genome-wide and associative genetic studies of the comorbid conditions under consideration in psychiatry is important for the development of biological and clinical predictors and a personalized therapy strategy for schizophrenia. However, it should be recognized that the problems of predictive and personalized psychiatry in the diagnosis and treatment of schizophrenia and comorbid disorders are far from being resolved.

Biases in diagnostic terminology: Clinicians choose different symptom labels depending on whether the same case is framed as depression or schizophrenia

Negative symptoms in schizophrenia show striking similarities to some depressive symptoms. Different terms are often used for these phenomenologically similar symptoms depending on the context, such as avolition (most often used in the context of schizophrenia) and lack of drive (most often used in the context of depression). To test whether clinicians assign different symptom labels to the same clinical picture based on the cued diagnosis, 98 clinical psychologists and psychiatrists were presented with two case studies that were randomly framed as characterizing an individual with either depression or schizophrenia. An interaction of the symptom label group selected by the clinicians with the framing condition confirmed our hypothesis: despite identical content, clinicians favored different clinical terms depending on the cued diagnosis (p = .025, η²_partial = 0.054). This result was supported by the suspected diagnosis suggested by the clinicians; numerically, they more often confirmed than rejected the cued diagnosis. The present study is in line with earlier findings indicative of strong overlap pertaining to the phenomenology of negative symptoms in schizophrenia and depressive symptoms that suggest that clinical terminology should be streamlined. The hypothesis that core symptoms of both syndromes tap largely the same construct should be further pursued. If true, the concept of negative symptoms, currently used to describe schizophrenia alone, should be opened up for describing symptoms in other disorders. This could help to gain a deeper understanding of the transdiagnostic appearances of the negative syndrome.

Measuring movements in adolescents with psychosis using the Microsoft Kinect sensor: a pilot study exploring a new tool for assessing aspects of antipsychotic-induced parkinsonism

BACKGROUND

The assessment of motor disturbances in antipsychotic-treated adolescent patients is often limited to the use of observer-based rating scales with interobserver variability. The objectives of this pilot study were to measure movement patterns associated with antipsychotic-induced parkinsonism in young patients with psychosis and initiating/treated with antipsychotics, using a computer application connected with the Microsoft Kinect sensor (Motorgame).

METHOD

All participants were assessed by neurological examination, clinical side effect rating scales (Udvalg for Kliniske Undersøgelser Side Effect Rating Scale, Barnes Akathisia Rating Scale, Simpson Angus Scale (SAS), and Abnormal Involuntary Movement Scale), and the Motorgame. Furthermore, speed of information processing and motor speed with subtests from the Brief Assessment of Cognition in Schizophrenia test battery was assessed.

RESULTS

We included 21 adolescents with first-episode psychosis (62% treated with antipsychotics; males 38%; mean age 16 ± 1.4 years) and 69 healthy controls (males 36%; mean age 16 ± 1.5 years). Prolonged time of motor performance (TOMP) in the Motorgame was associated with higher SAS scores for arm dropping (p = .009). A consistent practice effect was detected (p < .001). We found no significant associations between TOMP and age, height, body weight, sex, antipsychotic dosage, or information processing speed.

CONCLUSIONS

We found an uncorrected significant association between prolonged TOMP and shoulder bradykinesia. The Motorgame was found useful in assessing parkinsonian symptoms in early-onset psychosis and accepted by participants. Future studies of larger cohorts, including patients with high scores in clinical motor side effect scales, are required to establish solid validity of the novel test.

How Many Patients With Schizophrenia Do Not Respond to Antipsychotic Drugs in the Short Term? An Analysis Based on Individual Patient Data From Randomized Controlled Trials

OBJECTIVE

An important clinical question is how many patients with acute schizophrenia do not respond to antipsychotics despite being treated for adequate time and with an effective dose. However, up to date, the exact extent of the phenomenon remains unclear.

METHODS

We calculated the nonresponse and nonremission percentages using individual patient data from 16 randomized controlled trials (RCTs). Six thousand two hundred twenty-one patients were assigned to one antipsychotic (amisulpride, flupenthixol, haloperidol, olanzapine, quetiapine, risperidone, or ziprasidone) at an adequate dose; the response was assessed at 4-6 weeks. As various definitions of nonresponse have been used in the literature, we applied 4 different cut-offs covering the whole range of percent Positive and Negative Syndrome Scale (PANSS)/Brief Psychiatric Rating Scale (BPRS) reduction (≤0%, <25%, <50%, <75%).For symptomatic remission, we used the definition proposed by Andreasen without employing the time criterion.

RESULTS

The overall nonresponse for the cut-off of ≤0% PANSS/BPRS reduction was 19.8% (18.8%-20.8%); for the cut-off of <25% reduction it was 43% (41.7%-44.3%); for the cut-off of <50% reduction it was 66.5% (65.3%-67.8%); and for the cut-off of <75% reduction it was 87% (86%-87.9%). The overall percentage of no symptomatic remission was 66.9% (65.7%-68.1%). Earlier onset of illness, lower baseline severity and the antipsychotic used were significantly associated with higher nonresponse percentages.

CONCLUSIONS

Nonresponse and nonremission percentages were notably high. Nevertheless, the patients in our analysis could represent a negative selection since they came from short-term RCTs and could have been treated before study inclusion; thus, further response may not have been observed. Observational studies on this important question are needed.

The nature of bradykinesia in schizophrenia treated with antipsychotics

Recognizing drug-induced parkinsonian bradykinesia in psychosis patients can be challenging due to overlapping presentation with psychomotor slowing associated with depression, negative symptoms, or cognitive disturbances. In this study, we apply prior findings on the pathophysiology of bradykinesia in Parkinson's disease to gain an understanding of motor slowing in psychosis patients. Handwriting movements from 57 healthy participants and 70 psychosis patients were recorded on a digitizing tablet. Temporal and kinematic features were extracted from handwritten loops and circles. An independent objective measure based on peak velocity for circles written at maximum speed was used to classify patients as bradykinetic. Using a statistical cut-point derived from normative data, 64% of the patients met criterion for bradykinesia compared with 46% using a conventional observer-based severity rating scale. Bradykinetic patients produced handwriting movements with longer stroke durations, smaller amplitudes and lower peak velocities compared with non-bradykinetic patients. Thirty-six percent of the pen strokes produced by the bradykinetic patients were non-ballistic compare with 20% for the non-bradykinetic patients. The proportion of nonballistic movements observed in handwriting was unrelated to current antipsychotic dose, severity of negative psychosis or depression. The ease-of-use and standardization of a tablet-based approach to quantifying parkinsonian bradykinesia can aid in diagnosing parkinsonian bradykinesia in patients treated with antipsychotics.

Evidence for two distinct domains of negative symptoms: Confirming the factorial structure of the CAINS

Negative symptoms are an important predictor of course of illness as well as social and occupational functioning. Clinically effective interventions are scarce. For negative symptoms to become a reliable primary endpoint in treatment studies, clear operationalization and construct validation is needed. Recent factor analyses mostly find two main factors for negative symptoms: diminished expression und amotivation/anhedonia. The Clinical Assessment Interview for Negative Symptoms (CAINS) consists of the subscales "motivation and pleasure" and "expression". We assessed three samples of subjects with schizophrenia (n = 105) for different aspects of the scale's reliability and validity. A confirmatory factor analysis (CFA) of the CAINS confirmed its two-factorial structure. The subscales had distinct correlational profiles: "Motivation and pleasure" was strongly associated with functional outcome and depression and further with neurocognition, positive symptoms and social cognition. "Expression" seems independent of sources of secondary negative symptoms and neurocognition. We found good internal consistency and interrater agreement. Test-retest reliability (two-week interval) was moderate for the CAINS and its "expression" subscale and low for the "motivation and pleasure" subscale. Our findings indicate that the CAINS differentiates reliably between the two main domains of negative symptoms with some questions remaining concerning the validity of the "motivation and pleasure" subscale.

Structural equation modeling approach between salience network dysfunction, depressed mood, and subjective quality of life in schizophrenia: an ICA resting-state fMRI study

PURPOSE

Quality of life (QOL) is an important clinical outcome for patients with schizophrenia, and recent studies have focused on subjective QOL. We evaluated the causal relationship between psychosocial aspect of subjective QOL, symptoms, cognitive functions, and salience network (SN) dysfunction in schizophrenia using structural equation modeling (SEM).

PATIENTS AND METHODS

We performed a cross-sectional study of 21 patients with symptomatically stabilized schizophrenia and 21 age-, sex-, and education level-matched healthy controls who underwent resting-state functional magnetic resonance imaging. We evaluated SN dysfunction in schizophrenia using independent component analysis (ICA). We rated participant psychopathology using the Positive and Negative Syndrome Scale (PANSS), the Brief Assessment of Cognition in Schizophrenia (BACS), and the Calgary Depression Scale for Schizophrenia (CDSS). We rated psychosocial aspect of subjective QOL using the Schizophrenia Quality of Life Scale (SQLS) psychosocial subscale. We applied SEM to examine the relationships between SN dysfunction, PANSS positive and negative scores, CDSS total scores, BACS composite scores, and SQLS psychosocial subscale scores.

RESULTS

In second-level analysis after group ICA, patient group had significant lower right pallidum functional connectivity (FC) within the SN than the controls did (Montreal Neurological Institute [MNI] [x y z] = [22 -2 -6]) (p = 0.027, family-wise error [FWE] corrected). In SEM, we obtained a good fit for an SEM model in which SN dysfunction causes depressed mood, which in turn determines psychosocial aspect of subjective QOL (chi-squared p = 0.9, root mean square error of approximation (RMSEA) < 0.001, comparative fit index [CFI] = 1.00, and standardized root mean square residual [SRMR]= 0.020).

CONCLUSION

We found a continuous process by which SN dysfunction causes depressed moods that determine psychosocial aspect of subjective QOL in schizophrenia. This is the first report that offers a unified explanation of functional neuroimaging, symptoms, and outcomes. Future studies combining neuroimaging techniques and clinical assessments would elucidate schizophrenia's pathogenesis.

Secondary negative symptoms - A review of mechanisms, assessment and treatment

Negative symptoms in schizophrenia may be classified as primary or secondary. Primary negative symptoms are thought to be intrinsic to schizophrenia, while secondary negative symptoms are caused by positive symptoms, depression, medication side-effects, social deprivation or substance abuse. Most of the research on secondary negative symptoms has aimed at ruling them out in order to isolate primary negative symptoms. However, secondary negative symptoms are common and can have a major impact on patient-relevant outcomes. Therefore, the assessment and treatment of secondary negative symptoms are clinically relevant. Furthermore, understanding the mechanisms underlying secondary negative symptoms can contribute to an integrated model of negative symptoms. In this review we provide an overview of concepts, evidence, assessment and treatment for the major causes of secondary negative symptoms. We also summarize neuroimaging research relevant to secondary negative symptoms. We emphasize the relevance of recent developments in psychopathological assessment of negative symptoms, such as the distinction between amotivation and diminished expression, which have only rarely been applied in research on secondary negative symptoms.

Relationship of depression with cognitive insight and socio-occupational outcome in patients with schizophrenia

AIM

To evaluate the prevalence of depression using different measures in patients with schizophrenia and to study the relationship of depression in schizophrenia with cognitive insight and clinical insight, disability and socio-occupational functioning.

METHODS

A total of 136 patients with schizophrenia were evaluated for depression, cognitive insight and socio-occupational functioning.

RESULTS

Of the 136 patients included in the study, one-fourth ( N = 34; 25%) were found to have depression as per the Mini International Neuropsychiatric Interview (MINI). The prevalence of depression as assessed by Calgary Depression Scale for Schizophrenia (CDSS), Hamilton depression rating scale (HDRS) and Depressive Subscale of Positive and Negative Syndrome Scale (PANSS-D) was 23.5%, 19.9% and 91.9%, respectively. Among the different scales, CDSS has highest concordance with clinician's diagnosis. Sensitivity, specificity, positive predictive value and negative predictive value for CDSS was also higher than that noted for HDRS and PANSS-D. When those with and without depression as per clinician's diagnosis were compared, those with depression were found to have significantly higher scores on Positive and Negative Syndrome Scale (PANSS) positive and general psychopathology subscales, PANSS total score, participation restriction as assessed by P-scale and had lower level of functioning as assessed by Global Assessment of Functioning (GAF). No significant difference was noted on negative symptom subscale of PANSS, clinical insight as assessed on G-12 item of PANSS, disability as assessed by Indian Disability Evaluation and Assessment Scale (IDEAS) and socio-occupational functioning as assessed by Social and Occupational Functioning Assessment Scale (SOFS). In terms of cognitive insight, those with depression had significantly higher score for both the subscales, that is, self-reflective and self-certainty subscales as well as the mean composite index score.

CONCLUSION

Our results suggest that one-fourth of patients with schizophrenia have depression, compared to HDRS and PANSS-D, CDSS has highest concordance with clinician's diagnosis of depression and presence of depression is related to cognitive insight.

Comorbid Moderate-Severe Depressive Symptoms and their Association with Quality of Life in Chinese Patients with Schizophrenia Treated in Primary Care

This study described the prevalence and correlates of comorbid moderate-severe depressive symptoms (comorbid depression thereafter) and their association with quality of life (QOL) in schizophrenia patients treated in primary care. 623 schizophrenia patients were enrolled. Patients' socio-demographic and clinical characteristics including comorbid depression [defined as a total score of 18 or above on the Montgomery-Asberg Depression Rating Scale (MADRS)] were recorded. Depressive symptoms (defined as a total score of 9 or above on the MADRS) were present in 54.1 % of patients, while 17.7 % had comorbid depression. Analysis of covariance revealed that comorbid depression was significantly associated with lower mental QOL. Multiple logistic regression analysis revealed that more severe positive and negative symptoms, anxiety symptoms, use of first-generation antipsychotics and antidepressants, were independently associated with comorbid depression. Given the negative association between comorbid depression and QOL, attempts to address comorbid depression in schizophrenia patients treated in primary care should be made.

Lack of association between dopaminergic antagonism and negative symptoms in schizophrenia: a positron emission tomography dopamine D2/3 receptor occupancy study

RATIONALE

Several pre-clinical studies suggest that antipsychotic medications cause secondary negative symptoms. However, direct evidence for a relationship among antipsychotic medications, their direct effects on neurotransmitter systems, and negative symptoms in schizophrenia remains controversial.

OBJECTIVE

The objective of this study was to examine the relationship between antipsychotic-related dopamine D_2/3 receptor occupancy and negative symptoms in patients with schizophrenia.

METHODS

Forty-one clinically stable outpatients with schizophrenia participated in this prospective dose reduction positron emission tomography (PET) study. Clinical assessments and [¹¹C]-raclopride PET scans were performed before and after participants underwent gradual dose reduction of their antipsychotic medication by up to 40 % from the baseline dose.

RESULTS

No significant relationship was found between antipsychotic-related dopamine D_2/3 receptor occupancy and negative symptom severity at baseline or follow-up. Similar null findings were found for subdomains of negative symptoms (amotivation and diminished expression). Occupancy was significantly lower following dose reduction; however, negative symptom severity did not change significantly, though a trend toward reduction was noted. Examination of change scores between these two variables revealed no systematic relationship.

CONCLUSIONS

Our cross-sectional and longitudinal results failed to find a significant dose-dependent relationship between severity of negative symptoms and antipsychotic-related dopaminergic antagonism in schizophrenia. These findings argue against the notion that antipsychotics necessarily cause secondary negative symptoms. Our results are also in contrast with the behavioral effects of dopaminergic antagonism routinely reported in pre-clinical investigations, suggesting that the role of this variable in the context of chronic treatment and schizophrenia needs to be re-examined.

[Use of antidepressants in the treatment of negative symptoms of schizophrenia]

Negative symptoms account for a clinical dimension of schizophrenia. They are partly the cause of functional disability of this disease. Clinical experience shows that antipsychotics have little or no effect on these symptoms. The aim of this review is to gather existing data on the treatment of negative symptoms with antidepressants. The combination of antipsychotics with antidepressants is a therapeutic strategy commonly used for the treatment of these symptoms. The pro-dopaminergic effects of antidepressants explain their effectiveness on negative symptoms. There are many comparative, randomized, controlled studies evaluating the efficacy of antidepressant associated with antipsychotic for the treatment of negative symptoms. Furthermore three meta-analyses have been conducted. The overall results suggest that the use of antidepressants may contribute to clinical improvement of negative symptoms in schizophrenia. The limitations of these studies are the small number of patients included and the definition and assessment of negative symptoms. The existing scales are not sufficiently discriminating. Further research using new measurement tools should help refine these results.

Validity and Reliability of the Arabic Version of the Positive and Negative Syndrome Scale

BACKGROUND

The Positive and Negative Syndrome Scale (PANSS) is widely used for patients with schizophrenia. This scale is reliable and valid. The PANSS was translated and validated in several languages.

OBJECTIVE

The aim of this study was to translate and validate the PANSS in the Arab population.

SUBJECTS AND METHODS

The PANSS was translated into formal Arabic language using the back-translation method. 101 Arab patients with schizophrenia and 98 Arabs with no diagnosis of any mental disorder were recruited. The Arabic version of the Mini International Neuropsychiatric Interview (MINI-6) was used as a diagnostic tool to confirm the diagnosis of schizophrenia or rule out any diagnosis for the healthy control group. Reliability of the scale was assessed by calculating internal consistency, interrater reliability and test-retest reliability. Construct validity was assessed using the Arabic version of the MINI-6. PANSS total scores were correlated with the Clinical Global Impression-Severity scale.

RESULTS

Our findings showed that the internal consistency was good (0.92). Scores on the PANSS of the patients were much higher than those of the healthy controls. The PANSS showed good interrater reliability and test-retest reliability (0.92 and 0.75, respectively). In comparison with the MINI-6, the PANSS showed good sensitivity and specificity, which implies good construct validity of this version.

CONCLUSION

In conclusion, the Arabic version of the PANSS is a reliable and valid instrument for the assessment of patients with schizophrenia in the Arab population.

The course of negative symptoms over the first five years of treatment: Data from an early intervention program for psychosis

BACKGROUND

Cross-sectional studies suggest that negative symptoms are constituted by separable domains of reduced expressiveness and reduced motivation, but there is little data on the longitudinal course of these symptoms. We examined evidence for differences in the course and correlates of these two domains in a prospective study of patients presenting with a first episode of psychosis.

METHODS

Of 132 patients who were followed up for five years, it was possible to monitor reduced expressiveness and motivation on a weekly basis for 127. Information on treatment delay, premorbid adjustment, intellectual functioning, anxiety, depression and psychosocial functioning were also collected.

RESULTS

Over the five year follow-up, symptoms of reduced motivation occurred in 95.3% of patients and reduced expressiveness in 68.5%; and deficits in motivation were more likely to be unremitting (15.7%) than expressive deficits (5.5%). There were differences in the correlates of the proportion of time each patient experienced symptoms of each domain. Depression, weeks of full time occupation and weeks on a disability pension were associated with both domains. Anxiety was associated only with diminished motivation. Lower performance IQ; extrapyramidal symptoms (EPS) and dysrhythmic EEG were associated only with proportion of time showing reduced expressiveness.

CONCLUSIONS

The prospective data support previous cross-sectional findings that, while these domains of negative symptoms are correlated, they do show differences in prevalence over time and in their correlates.

Racial disparities during admission to an academic psychiatric hospital in a large urban area

Multiple studies confirm that African Americans are less likely than non-Hispanic whites to receive needed mental health services. Research has consistently shown that African Americans are under-represented in outpatient mental health treatment settings and are over-represented in inpatient psychiatric settings. Further, African Americans are more likely to receive a diagnosis of schizophrenia and are less likely receive an affective disorder diagnosis during inpatient psychiatric hospitalization compared to non-Hispanic white patients, pointing to a need for examining factors contributing to mental health disparities. Using Andersen's Behavioral Model of Health Service Use, this study examined predisposing, enabling and need factors differentially associated with health service utilization among African American and non-Hispanic white patients (n=5183) during psychiatric admission. We conducted univariate and multivariate logistic regression analyses to examine both main effects and interactions. In the multivariate model, African American race at admission was predicted by multiple factors including younger age, female gender, multiple psychiatric hospitalizations, elevated positive and negative symptoms of psychosis, a diagnosis of schizophrenia and substance use, as well as having housing and commercial insurance. Additionally, screening positive for cannabis use at intake was found to moderate the relationship between being female and African American. Our study findings highlight the importance of examining mental health disparities using a conceptual framework developed for vulnerable populations (such as racial minorities and patients with co-occurring substance use).

Antipsychotics and amotivation

Antipsychotic drugs are thought to produce secondary negative symptoms, which can also exacerbate primary negative symptoms. In the present study, we examined whether motivational deficits in particular were related to antipsychotic treatment in patients with schizophrenia in a dose-dependent manner. Five hundred and twenty individuals with schizophrenia who were receiving antipsychotic monotherapy for at least 6 months and followed prospectively were included in the present study. Participants were receiving one of five antipsychotic medications (olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone), and analyses were conducted for patients receiving each drug separately. Analysis of covariance models were constructed to examine the effect of antipsychotic dose on level of motivational impairment, controlling for selected demographic and clinical variables (eg, positive symptoms). Level of motivation, or deficits therein, were evaluated using a derived measure from the Quality of Life Scale, and in addition with scores derived from the Positive and Negative Syndrome Scale. Antipsychotic dose was not related to the level of amotivation for any of the medications examined. Moreover, severity of sedation was not significantly related to the degree of amotivation. One hundred and twenty-one individuals were identified as antipsychotic-free at baseline, and after 6 months of antipsychotic treatment, no change in motivation was found. Chronic treatment with antipsychotics does not necessarily impede or enhance goal-directed motivation in patients with schizophrenia. It is possible that the negative impact of antipsychotics in this regard is overstated; conversely, the present results also indicate that we must look beyond antipsychotics in our efforts to improve motivation.

Testosterone levels and clinical features of schizophrenia with emphasis on negative symptoms and aggression

BACKGROUND

Aggressive behavior and negative symptoms are two features of schizophrenia that may have a hormonal basis.

AIM

The aim of this study was to compare testosterone level with clinical features of schizophrenia, focusing on negative symptoms and aggressive behavior.

METHODS

The study population consisted of 120 male schizophrenic patients (ages 18-40) classified into non-aggressive (n = 60) and aggressive (n = 60) groups. Depending on the type of aggression that was manifested prior to admission, the aggressive group was divided into violent (n = 32) and suicidal (n = 28) subgroups. Psychopathological severity, violence and suicidality were assessed using the Positive and Negative Syndrome Scale (PANSS), Overt Aggression Scale and Columbia Suicide Severity Rating Scale, respectively. Total serum testosterone level was determined on the same morning that symptoms were assessed.

RESULTS

In the non-aggressive group, testosterone level was negatively correlated with the score on the negative subscale of PANSS (P = 0.04) and depression (P = 0.013), and positively correlated with excitement (P = 0.027), hostility (P = 0.02) and impulsive behavior (P = 0.008). In the aggressive group, testosterone level had non-significant correlation with these parameters, and with violent or suicidal behavior.

CONCLUSIONS

The results confirmed that non-aggressive male schizophrenic patients with lower levels of testosterone had a greater severity of negative symptoms. In aggressive patients, there was no correlation between testosterone and clinical features of the disorder or the degree or type of aggression. These findings indicate that therapeutic strategies targeting testosterone could be useful in the treatment of negative symptoms of schizophrenia.

Schizophrenia and Depression Co-Morbidity: What We have Learned from Animal Models

Patients with schizophrenia are at an increased risk for the development of depression. Overlap in the symptoms and genetic risk factors between the two disorders suggests a common etiological mechanism may underlie the presentation of comorbid depression in schizophrenia. Understanding these shared mechanisms will be important in informing the development of new treatments. Rodent models are powerful tools for understanding gene function as it relates to behavior. Examining rodent models relevant to both schizophrenia and depression reveals a number of common mechanisms. Current models which demonstrate endophenotypes of both schizophrenia and depression are reviewed here, including models of CUB and SUSHI multiple domains 1, PDZ and LIM domain 5, glutamate Delta 1 receptor, diabetic db/db mice, neuropeptide Y, disrupted in schizophrenia 1, and its interacting partners, reelin, maternal immune activation, and social isolation. Neurotransmission, brain connectivity, the immune system, the environment, and metabolism emerge as potential common mechanisms linking these models and potentially explaining comorbid depression in schizophrenia.

Schizophrenia is primed for an increased expression of depression through activation of immuno-inflammatory, oxidative and nitrosative stress, and tryptophan catabolite pathways

Schizophrenia and depression are two common and debilitating psychiatric conditions. Up to 61% of schizophrenic patients have comorbid clinical depression, often undiagnosed. Both share significant overlaps in underlying biological processes, which are relevant to the course and treatment of both conditions. Shared processes include changes in cell-mediated immune and inflammatory pathways, e.g. increased levels of pro-inflammatory cytokines and a Th1 response; activation of oxidative and nitrosative stress (O&NS) pathways, e.g. increased lipid peroxidation, damage to proteins and DNA; decreased antioxidant levels, e.g. lowered coenzyme Q10, vitamin E, glutathione and melatonin levels; autoimmune responses; and activation of the tryptophan catabolite (TRYCAT) pathway through induction of indoleamine-2,3-dioxygenase. Both show cognitive and neurostructural evidence of a neuroprogressive process. Here we review the interlinked nature of these biological processes, suggesting that schizophrenia is immunologically primed for an increased expression of depression. Such a conceptualization explains, and incorporates, many of the current perspectives on the nature of schizophrenia and depression, and has implications for the nature of classification and treatment of both disorders. An early developmental etiology to schizophrenia, driven by maternal infection, with subsequent impact on offspring immuno-inflammatory responses, creates alterations in the immune pathways, which although priming for depression, also differentiates the two disorders.

Prevalence of depression and its relationship with other clinical characteristics in a sample of patients with stable schizophrenia

AIM

To evaluate the prevalence of depression using the Calgary Depression Scale for Schizophrenia (CDSS) in a sample of Spanish patients with stable schizophrenia and without a diagnosis of depression.

METHODS

We included stable outpatients of 18 to 50 years of age, with a diagnosis of schizophrenia, schizoaffective disorder, or schizophreniform disorder who had not been diagnosed with depression. In this cross-sectional study, we administered the CDSS, the Positive and Negative Syndrome Scale (PANSS), the Scale for the Assessment of Negative Symptoms (SANS), the Scale to Assess Unawareness of Mental Disorder (SUMD), the Simpson Angus Scale (SAS), and the Barnes Akathisia Rating Scale (BARS).

RESULTS

A total of 95 patients were recruited, 90 of them were included in the statistical analysis. Twenty-eight patients had a total score of 5 or more points on the CDSS, making the prevalence of depression 31% (95% confidence interval, 22-41). The CDSS had a high correlation with the depressive factor of the PANSS and a moderate correlation with the general psychopathology subscale of the PANSS. The correlation of the CDSS total score with negative symptoms was moderate using the SANS and low with the PANSS-negative. There was no correlation between depressive symptoms and positive symptoms, insight, and extrapyramidal symptoms; and the correlation with akathisia was low.

CONCLUSION

Our results suggest that patients with stable schizophrenia who have not been diagnosed with depression frequently have clinically relevant symptoms of depression, and that these symptoms, with the possible exception of a contribution from negative symptoms, are not secondary to other symptoms of their disorder or to extrapyramidal adverse effects of medications.

Reliability and validity of the Chinese version of the Calgary Depression Scale for Schizophrenia

OBJECTIVE

The aim of the present study was to determine the reliability and validity of the Chinese version of the Calgary Depression Scale for Schizophrenia (CDSS-C) in schizophrenia patients.

METHOD

One hundred and one inpatients from four mental health units who met DSM-IV criteria for schizophrenia were enrolled. The Positive and Negative Syndrome Scale (PANSS), Hamilton Depression Rating Scale (HDRS-24), Simpson-Augus Rating Scale (SAS), and Barnes Acathisia Rating Scale (BARS) were administered by the first rater, whereas the CDSS-C was assessed by a second independent rater.

RESULTS

The internal consistency (Cronbach's alpha = 0.80) and the inter-rater reliability (kappa coefficient >0.79) were good. The test-retest reliability was high (r = 0.927). The scale had good construct validity, with statistically significant correlations with the HDRS-24, G6 item (depression) of PANSS, and significant weak correlations with the general psychopathology subscale of PANSS. The CDSS-C showed no correlation with the positive and negative subscale of PANSS, the SAS and the BARS.

CONCLUSION

The Chinese version of CDSS is a valid and reliable instrument for the assessment of depression in schizophrenia.

Direct and indirect effects of paliperidone extended-release tablets on negative symptoms of schizophrenia

Direct and indirect effects of the new psychotropic paliperidone extended-release (paliperidone ER) tablets on negative symptom improvement in schizophrenia were investigated using path analysis. A post hoc analysis of pooled data from three 6-week, double-blind, placebo-controlled studies of paliperidone ER in patients experiencing acute exacerbation was conducted. Regression analysis explored relationships between baseline/study characteristics and negative symptoms. Change in Positive and Negative Syndrome Scale (PANSS) negative factor score at endpoint was the dependent variable; explanatory variables included demographic and clinical characteristics. Path analysis determined direct and indirect effects of treatment on negative symptom change. Indirect mediators of negative symptom change in the model included changes in positive symptoms, anxiety/depression symptoms and movement disorders. Path analysis indicated that up to 33% of negative symptom improvement was a direct treatment effect. Indirect effects on negative symptoms were mediated through changes in positive symptoms (51%) and anxiety/depression symptoms (18%), whereas changes in movement disorders had a 2.1% inverse effect. Path analysis indicated that paliperidone ER has a direct effect on negative symptoms. Negative symptom improvement also was indirectly mediated via changes in positive and depressive symptoms.

Short-term testosterone augmentation in male schizophrenics: a randomized, double-blind, placebo-controlled trial

Although there are few studies on the treatment of schizophrenia with testosterone, several indirect findings have suggested testosterone as a possible treatment modality for schizophrenia. To explore the therapeutic effect of testosterone augmentation of antipsychotic medication on symptoms in male patients with schizophrenia, the authors performed a placebo-controlled, double-blind trial on 30 schizophrenic men, using either 5 g of 1% testosterone gel (Testogel; Besins Iscovesco, Paris, France) or a placebo added to a fixed dosage of antipsychotic medication over a period of 4 weeks with a 2-week washout period. In addition, to get additional information about the involvement of these reproductive hormones after testosterone augmentation, the authors evaluated several hormones such as total testosterone, free testosterone, dehydroepiandrosterone sulfate, estradiol, and prolactin. Results indicated a significant improvement of negative symptoms in both the last observation carried forward and the completer analyses and a nonsignificant trend for the improvement of depressive symptoms in completers. There were no significant changes in serum hormone levels except total and free testosterone. The findings of this study suggest that testosterone augmentation may be a potential therapeutic strategy in patients with schizophrenia.

Association between serum testosterone levels and the severity of negative symptoms in male patients with chronic schizophrenia

OBJECTIVES

Dysfunction of the hypothalamic-pituitary-gonadal axis may contribute to the pathophysiology of schizophrenia. Recent neuroendocrinological studies have suggested that gonadal sex hormones, including androgens and estrogen, play a significant role in the pathophysiology of schizophrenia. The purpose of this study was to determine any correlation between negative symptoms and the plasma levels of free testosterone, total testosterone, dehydroepiandrosterone sulfate, estradiol, and prolactin with consideration to depressive symptoms, extrapyramidal symptoms (EPS), and other factors including differences in age, diurnal variation of the serum hormone levels, and body fat composition.

METHODS

The subjects were 35 male inpatients with chronic schizophrenia aged 20-39 years. The patients' psychopathology was assessed using the Positive and Negative Syndrome Scale (PANSS). The Calgary Depression Scale for Schizophrenia (CDSS) and the Drug-induced EPS scale (DIEPSS) were also used to exclude the effects of depression or drug-induced movement disorders.

RESULTS

The PANSS negative scores had a significant inverse correlation with the serum total and free testosterone levels. The other hormone levels were not correlated with the PANSS negative scores. Moreover, a partial correlation analysis showed an inverse correlation between the PANSS negative subscores and the serum total and free testosterone levels after controlling for the DIEPSS and/or CDSS scores and age.

CONCLUSIONS

This study indicates that total and free testosterone may play an important role in the severity of negative symptoms in male patients with schizophrenia.

Dysfunction of ventral striatal reward prediction in schizophrenic patients treated with typical, not atypical, neuroleptics

RATIONALE

Clinical studies in patients with schizophrenia suggest that atypical neuroleptics are more effective than typical neuroleptics in reducing negative symptoms including apathy and anhedonia. Dysfunction of the dopaminergic reward system may contribute to negative symptoms in schizophrenia.

OBJECTIVE

We used functional magnetic resonance imaging to assess the blood oxygen level dependency response in the ventral striatum of medicated schizophrenics and healthy control subjects during reward anticipation.

METHODS

Twenty schizophrenics [ten medicated with typical (e.g., haloperidol) and ten with atypical (e.g., olanzapine and risperidone) neuroleptics] and ten age-matched healthy volunteers participated in an incentive monetary delay task in which visual cues predicted that a rapid response to a subsequent target stimulus would result either in monetary gain or no consequence.

RESULTS

Healthy volunteers and schizophrenics treated with atypical neuroleptics showed ventral striatal activation in response to reward-indicating cues, but schizophrenics treated with typical neuroleptics did not. In patients treated with typical neuroleptics, decrease in activation of the left ventral striatum was correlated with the severity of negative symptoms.

CONCLUSIONS

Failure to activate the ventral striatum during reward anticipation was previously associated with the severity of negative symptoms in schizophrenia and was also found in schizophrenics treated with typical neuroleptics in this study. Significant blunting of ventral striatal activation was not observed in patients treated with atypical neuroleptics, which may reflect the improved efficacy of these drugs in treating negative symptoms.

Emotional processing in schizophrenia

INTRODUCTION

Persons with schizophrenia have impaired emotional processing, involving experience, expression, and recognition of emotions.

METHODS

This article reviews the historical descriptions and more recent work on emotion processing in schizophrenia.

RESULTS

Although abilities of emotional processing relate directly to interpersonal communication and psychosocial functioning, methodological issues exist in the current body of studies and resultant knowledge, which limit translation to novel treatment options.

CONCLUSIONS

Further improvement in emotion processing in persons with stable schizophrenia are unlikely to result from conventional pharmacotherapy of psychosis. New treatment modalities and behavioural interventions offer possible improvements in quality of life and psychosocial functioning.

Critical assessment of how to study addiction and its treatment: human and non-human animal models

Laboratory models, both animal and human, have made enormous contributions to our understanding of addiction. For addictive disorders, animal models have the great advantage of possessing both face validity and a significant degree of predictive validity, already demonstrated. Another important advantage to this field is the ability of reciprocal interplay between preclinical and clinical experiments. These models have made important contributions to the development of medications to treat addictive disorders and will likely result in even more advances in the future. Human laboratory models have gone beyond data obtained from patient histories and enabled investigators to make direct observations of human drug self-administration and test the effects of putative medications on this behavior. This review examines in detail some animal and human models that have led not only to important theories of addiction mechanisms but also to medications shown to be effective in the clinic.

Dysfunction of ventral striatal reward prediction in schizophrenia

BACKGROUND

Negative symptoms may be associated with dysfunction of the brain reward system in schizophrenia. We used functional magnetic resonance imaging (fMRI) to assess the BOLD response in the ventral striatum of unmedicated schizophrenics during presentation of reward-indicating and loss-indicating stimuli.

METHODS

A total of 10 schizophrenic men (7 never medicated, 3 unmedicated for at least 2 years) and 10 age-matched healthy male volunteers participated in an incentive monetary delay task, in which visual cues predicted that a rapid response to a subsequent target stimulus would result either in monetary gain or loss or would have no consequence.

RESULTS

Compared to healthy controls, unmedicated schizophrenics showed reduced ventral striatal activation during the presentation of reward-indicating cues. Decreased activation of the left ventral striatum was inversely correlated with the severity of negative (and trendwise positive) symptoms.

DISCUSSION

Reduced activation in one of the central areas of the brain reward system, the ventral striatum, was correlated with the severity of negative symptoms in medication-free schizophrenics. In unmedicated schizophrenic patients, a high striatal dopamine turnover may increase the "noise" in the reward system, thus interfering with the neuronal processing of reward-predicting cues by phasic dopamine release. This, in turn, may contribute to negative symptoms as such as anhedonia, apathy, and loss of drive and motivation.

Depressive and negative symptoms in schizophrenia: different effects on clinical features

OBJECTIVE

The primary aim of this study was to investigate whether depressive symptoms were significantly associated with functional outcome measures in a clinically stable group of outpatients with schizophrenia. We also analyzed whether depressive and negative symptoms presented different patterns of predictors.

METHOD

Seventy-eight consecutive outpatients meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for schizophrenia in the stable period were enrolled in this cross-sectional study. Assessment were performed using the Calgary Depression Scale for Schizophrenia, Positive and Negative Syndromes Scale (PANSS), Clinical Global Impression Scale-severity, Social and Occupational Functioning Assessment Scale, Sheehan Disability Scale, and Quality of Life Scale. A neuropsychologic battery including the vocabulary and block design subtests of the Wechsler Adult Intelligence Scale-Revised, Wechsler Memory Scale, Wisconsin Card Sorting Test, and Continuous Performance Test was also administered to the patients. Two multiple regressions were performed testing demographic and clinical factors, rating scales, and cognitive measures as independent variables and Calgary Depression Scale for Schizophrenia and PANSS-negative subscale scores as dependent variables.

RESULTS

Four variables were predictors of depressive symptoms in our sample of schizophrenic patients: 2 outcome measures (Sheehan Disability Scale and Quality of Life Scale), gender, and Continuous Performance Test reaction time. Predictors of negative symptoms were the measures of severity of psychopathology (Clinical Global Impression Scale-severity and PANSS-general psychopathology subscale) and the cognitive tests Wechsler Adult Intelligence Scale-Revised block design and Wechsler Memory Scale.

CONCLUSION

We found that depressive symptoms in schizophrenia are mainly a function of the level of social adjustment and quality of life, whereas negative symptoms constitute an indicator of severity of schizophrenia. The 2 symptom dimensions showed also distinct cognitive correlates.

Extrapyramidal symptoms in unmedicated schizophrenia

Studies of spontaneous extrapyramidal symptoms, dyskinesia and parkinsonism, in unmedicated schizophrenia are of importance in understanding their underlying pathology and relation to the psychosis. This is a study of extrapyramidal symptoms using Abnormal Involuntary Movements Scale for dyskinesia and Simpson-Angus Scale for parkinsonism in 143 schizophrenia patients who never received antipsychotic medication. Psychopathology was measured using the Positive and Negative Syndrome Scale. Dyskinesia was present in 35% of patients and parkinsonism in 15%. The two disorders coexisted in 11 subjects. Orofacial dyskinesia, rigidity and tremor were common symptoms noted. There was no significant change in the rates and total scores of dyskinesia and parkinsonism with gender, age, duration of illness or age at onset of psychosis. Dyskinesia was unrelated to psychopathology. Parkinsonism score correlated positively with the motor symptom cluster of psychopathology. Dyskinesia and parkinsonism scores correlated positively with each other and parkinsonism score discriminated presence of dyskinesia. The associations between the spontaneous abnormal movements and other aspects of schizophrenia differed from those described in treated patients. Dyskinesia and parkinsonism are an integral part of the schizophrenia disease process whose relationship with other factors could be influenced by antipsychotic drug treatment.

Subjective distress related to side effects and subjective well-being in first admitted adolescents with early-onset psychosis treated with atypical antipsychotics

OBJECTIVE

Side effects (SE) of antipsychotics are considered a major source of subjective discomfort. The aim of this pilot study was to evaluate the subjective distress-related to different SE and its association with subjective well-being in a sample of adolescents treated with atypical antipsychotics.

METHODS

Subjects enrolled were first hospitalized adolescent inpatients with diagnoses of Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) schizophrenia, schizophreniform, or schizoaffective disorder. Subjects' Clinical Global Impression-Severity (CGI-S) and subjective well-being (SWN-K, BfS) were evaluated at baseline, week 2, and week 6. Side effects (UKU) and subjective distress under SE (Subjective Distress Scale, SDS) were evaluated at weeks 2 and 6.

RESULTS

Twenty adolescents were included. Almost all subjects suffered from at least one distressing SE at both follow-up time points. The mean number of distressing SE decreased from weeks 2 to 6. The most prevalent distressing SE were psychic SE and weight gain. There was an association between distress related to psychic and neurological SE and negative subjective wellbeing (r = 0.60-0.70). Subjective distress with these SE, especially neurological SE at both time points and sedation-increased sleep at week 6, did not correspond to clinician's severity ratings.

CONCLUSIONS

Clinicians may overlook distress by only judging the severity of SE objectively in the treatment with atypical antipsychotics, leading to negative subjective well-being and a high rate of nonadherence to treatment. Therefore, it is recommended to discuss the severity of, and distress with, SE independently with patients. Future studies should focus on distress related to neurological SE, sedation, and weight gain.

Validity of Simpson-Angus Scale (SAS) in a naturalistic schizophrenia population

BACKGROUND

Simpson-Angus Scale (SAS) is an established instrument for neuroleptic-induced parkinsonism (NIP), but its statistical properties have been studied insufficiently. Some shortcomings concerning its content have been suggested as well. According to a recent report, the widely used SAS mean score cut-off value 0.3 of for NIP detection may be too low. Our aim was to evaluate SAS against DSM-IV diagnostic criteria for NIP and objective motor assessment (actometry).

METHODS

Ninety-nine chronic institutionalised schizophrenia patients were evaluated during the same interview by standardised actometric recording and SAS. The diagnosis of NIP was based on DSM-IV criteria. Internal consistency measured by Cronbach's alpha, convergence to actometry and the capacity for NIP case detection were assessed.

RESULTS

Cronbach's alpha for the scale was 0.79. SAS discriminated between DSM-IV NIP and non-NIP patients. The actometric findings did not correlate with SAS. ROC-analysis yielded a good case detection power for SAS mean score. The optimal threshold value of SAS mean score was between 0.65 and 0.95, i.e. clearly higher than previously suggested threshold value.

CONCLUSION

We conclude that SAS seems a reliable and valid instrument. The previously commonly used cut-off mean score of 0.3 has been too low resulting in low specificity, and we suggest a new cut-off value of 0.65, whereby specificity could be doubled without loosing sensitivity.

Correlates of subjective well-being in schizophrenic patients treated with atypical antipsychotics

Objective A growing body of research indicates that a low subjective well-being (SW) may be predictive of non-adherence and less favourable outcome. This study examined baseline variables and variables in the course of treatment hypothesised to be associated with later SW. Methods Sixty-three inpatients with schizophreniform disorder or schizophrenia were randomly assigned to treatment with various atypical antipsychotics after a wash-out phase of 2 days. Subjects were evaluated with a protocol that examined psychopathology (Positive and Negative Symptom Scale, PANSS), side effects (Scandinavian Society of Pharmacology, UKU), and subjective well-being (Subjective Well-being under Neuroleptic treatment, SWN) at baseline and endpoint (mean duration of treatment 39.9 days). Two-thirds of subjects were multiple episode schizophrenic inpatients pre-treated with antipsychotics. Results Multiple regression analyses revealed that the PANSS negative score, neurological side effects, and SWN at baseline, as well as change of the PANSS positive score between baseline and endpoint, were associated independently with SW at endpoint (R(2)=0.55 after exclusion of two subjects). Conclusions Patients with low SW, severe negative symptoms, and neurological side effects, all at baseline, as well as those without improvement or deterioration of positive symptoms are at risk of low SW later in treatment and, most likely, of non-adherence.

Management of the negative symptoms of schizophrenia: new treatment options

This article presents a systematic review of pharmacological treatment for negative symptoms of schizophrenia, based on MEDLINE searches from 1995 to September 2002 to identify pertinent clinical trials. The pharmacotherapy of negative symptoms in schizophrenia includes novel/atypical antipsychotics and classical antipsychotics, as well as antidepressants, glutamatergic compounds, antiepileptic drugs and estrogens. In the assessment of therapy for negative symptoms of schizophrenia, it is imperative that better studies of sound methodology are performed. In such studies, some important aspects to be considered include an accurate definition and assessment of negative symptoms (including well designed, valid and reliable rating scales), the differentiation between primary and secondary negative symptoms, an appropriate selection of standard comparators, adequate dosages of comparators (e.g. haloperidol dosages) and an overall optimal study design. Most of the available studies on treating negative symptoms in schizophrenia have focused on the atypical antipsychotics, while other potential candidates, mostly in the context of add-on therapy, have not been so intensively investigated. Atypical antipsychotics have been proven in placebo-controlled trials to be effective in treating negative symptoms of acute schizophrenic episodes. In many of the comparator studies, they showed efficacy in treating negative symptoms that was superior to that of typical antipsychotics. Data on stable, predominant negative symptoms in subchronic or chronic cases of schizophrenia, although limited, have demonstrated the efficacy of atypical antipsychotics. If the beneficial tolerability profile with respect to extrapyramidal symptoms is also taken into account during clinical decision making, the atypical antipsychotics should be preferred for the treatment of negative symptoms. It is also worth noting that the traditional antipsychotics have the risk of inducing negative symptoms in the context of akinesia. The benefits of add-on therapy with SSRIs or a glutamatergic compound are well documented. Estrogen add-on therapy seems promising. Other traditionally suggested approaches, such as comedication with an antiepileptic drug, lithium or beta-adrenoceptor antagonist, cannot generally be recommended on the basis of the available data.

Depression in paranoid and nonparanoid schizophrenic patients compared with major depressive disorder

BACKGROUND

Depression occurring in schizophrenia is a common problem; however, investigators have typically not studied it with the paranoid/nonparanoid dichotomy in mind. This study examines the quality as well as the severity of depression in three psychiatric groups: paranoid schizophrenia patients, nonparanoid schizophrenia patients, and nonpsychotic major depression patients.

METHOD

Clinical and sociodemographic data were collected on 27 paranoid and 27 nonparanoid schizophrenia patients during their postpsychotic phase while they were at least mildly depressed, and a comparison group of 27 nonpsychotic patients diagnosed with major depressive disorder. The three groups were then assessed on various psychometric scales for severity of depression, profile of symptoms, suicidal risk, and anhedonia.

RESULTS

The paranoid schizophrenia patients were more depressed and more at risk for suicide than the nonparanoid schizophrenia patients, yet their depressive profiles and levels of anhedonia were similar.

CONCLUSIONS

Depressed mood and anhedonia constitute serious problems for schizophrenia patients, but particularly for paranoid schizophrenia patients during the postpsychotic phase of their illnesses.

CLINICAL IMPLICATIONS

Schizophrenia patients, especially those with the paranoid features, should be routinely evaluated and monitored for depression. Apart from treatment with drugs, cognitive therapy may be considered a viable option, particularly for paranoid schizophrenia patients.

LIMITATIONS

Gender was not matched for the two schizophrenia groups and extrapyramidal side effects were not measured.

Postpsychotic depression in schizophrenia patients

Depression is a frequent comorbidity in the course of schizophrenia and is associated with increased mortality from suicide. Postpsychotic depression is defined as the syndrome of major depression occurring following remission of psychotic symptoms in a person with schizophrenia. Various proposed causes, differential diagnosis, and issues regarding management of postpsychotic depression are discussed.

Depressive, positive, negative and parkinsonian symptomsin schizophrenia

OBJECTIVE

Depressive symptoms are common in schizophrenia but their relationship to the positive and negative symptoms of the disorder and to extrapyramidal side-effects remains unclear. Considerable overlap exists between these symptom clusters when rated with traditional clinical rating scales. The aim of this study was to investigate the relationship of depressive to positive, negative and parkinsonian symptoms using the recent adaptation of the Positive and Negative Syndrome Scale (PANSS).

METHOD

The study involved the cross-sectional measurement of symptoms in a sample of community-treated and hospitalized patients with schizophrenia. Structured assessment included thePANSS, Montgomery-Asberg Depression Rating Scale (MADRS) and the Extrapyramidal Side Effects Rating Scale (ESRS).

RESULTS

Depressive symptoms were common and correlated with positive and negative symptoms. These correlations were of a similar magnitude using either the original PANSS factor structure or the newer pentagonal model. The overlap between depressive and negative symptoms was limited to certain items in the rating scales and there was a clear separation between these symptom clusters and the other items. Parkinsonian symptoms also correlated with negative symptoms rated with either PANSS model.

CONCLUSION

Use of the pentagonal PANSS model does not improve its capacity to distinguish between depressive and negative symptoms. Positive, negative, parkinsonian and depressive symptoms overlap using common rating scales but there appears to be some separation between these symptom domains when rated with individual scale items rather than total scale scores.

Depressive symptoms in stable chronic schizophrenia: prevalence and relationship to psychopathology and treatment

The prevalence and correlates of the depressive syndrome were explored in a population of 120 patients with stable, chronic schizophrenia living in the community. The presence of clinically significant depressive symptoms was defined by a score of 17 or greater on the Beck Depression Inventory. Patients were examined to assess severity of schizophrenic symptoms and medication side-effects. Sixteen of the 120 patients (13.3%) had significant depressive symptoms. Depressive symptoms were significantly correlated with the hostility/suspiciousness (P<0.0001), the positive symptom (P=0.0009) factor of the BPRS and with scores on the Significant Others Scale, a measure of patients' perceived lack of social support (P=0.0004). The association between depression and akathisia approached significance (P=0.007). There was no correlation with demographic variables, alcohol intake, antipsychotic dosage or anticholinergic dosage. Using a scale that rates the subjective aspects of the depressive syndrome, we found no evidence of a relationship between depression and negative symptoms in this population. These results indicate that persistent depressive symptoms in stable patients in the community are related to the degree of persistent positive psychotic symptoms, patient perceptions of social support and, weakly, to the degree of akathisia but not other aspects of antipsychotic treatment.

Extrapyramidal symptoms and residual psychopathology with low-dose neuroleptics

Residual psychopathology associated with EPS has been mainly assessed in experimental studies where neuroleptics were administered at standard, fixed dosages. The present study evaluates residual psychopathology in 69 schizophrenic patients treated with moderate, flexible doses of neuroleptics (430 mg eq. CPZ) at the out-patient Community Mental Health Services (CMHSs) in Bologna. Akathisia was present in 27.5 per cent of patients and parkinsonism in 27.5 per cent. A more severe psychopathological state was associated with both side-effects, as seen by significantly higher BPRS global scores. This severity was due to tension and anxiety-depression symptoms in patients with akathisia and to negative symptomatology in patients with parkinsonism, as shown by significant associations with BPRS subscales ANS-DEP and NEG, respectively. In conclusion, the present study underlines that EPS are frequent even in an out-patient setting where moderate neuroleptic doses are employed, and more importantly shows that in these conditions, the residual psychopathology resulting from EPS is clinically very significant. Copyright 2000 John Wiley & Sons, Ltd.

Motor and cognitive aspects of motor retardation in depression

BACKGROUND

Motor retardation is a common feature of major depressive disorder having potential prognostic and etiopathological significance. According to DSM-IV, depressed patients who meet criteria for psychomotor retardation, must exhibit motor slowing of sufficient severity to be observed by others. However, overt presentations of motor slowing cannot distinguish slowness due to cognitive factors from slowness due to neuromotor disturbances.

METHODS

We examined cognitive and neuromotor aspects of motor slowing in 36 depressed patients to test the hypothesis that a significant proportion of patients exhibit motor programming disturbances in addition to psychomotor impairment. A novel instrumental technique was used to assess motor programming in terms of the subject's ability to program movement velocity as a function of movement distance. A traditional psychomotor battery was combined with an instrumental measure of reaction time to assess the cognitive aspects of motor retardation.

RESULTS

The depressed patients exhibited significant impairment on the velocity scaling measure and longer reaction times compared with nondepressed controls. Approximately 40% of the patients demonstrated abnormal psychomotor function as measured by the traditional battery; whereas over 60% exhibited some form of motor slowing as measured by the instruments. Approximately 40% of the patients exhibited parkinsonian-like motor programming deficits. A five-factor model consisting of motor measures predicted diagnosis among bipolar and unipolar depressed patients with 100% accuracy.

LIMITATIONS

The ability of motor measures to discriminate bipolar from unipolar patients must be viewed with caution considering the relatively small sample size of bipolar patients.

CONCLUSIONS

These findings suggest that a subgroup of depressed patients exhibit motor retardation that is behaviorally similar to parkinsonian bradykinesia and may stem from a similar disruption within the basal ganglia.

Negative parkinsonian, depressive and catatonic symptoms in schizophrenia: a conflict of paradigms revisited

BACKGROUND

To study the interrelationship pattern of negative, depressive, parkinsonian and catatonic symptoms over an exacerbation phase of schizophrenia.

METHOD

Forty-five inpatients with a DSM-IV diagnosis of schizophrenia or schizophreniform disorder were assessed at admission and discharge for negative, depressive, parkinsonian and catatonic symptoms. A subsample of patients unmedicated at admission (n=23) was specifically analyzed.

RESULTS

Negative, parkinsonian and catatonic symptoms correlated significantly at both assessment points, as did their mean changes over the episode. At admission, depressive symptoms did not correlate with negative, parkinsonian or catatonic symptoms, but they did at discharge. Changes of depressive symptoms over the episode did not correlate with changes of the other groups of symptoms. In the patients who were unmedicated at admission, ratings of nonakinetic parkinsonism, unlike ratings of akinetic parkinsonism, worsened significantly after neuroleptic treatment.

CONCLUSIONS

While negative, parkinsonian and catatonic symptoms are highly related features, depressive symptoms seem to be a relatively independent dimension of psychopathology in schizophrenia. Non-akinetic parkinsonian symptoms may be more useful than the akinetic symptoms in distinguishing primary from drug-induced negative symptoms.

Evaluation of depression in schizophrenia: psychometric properties of a French version of the Calgary Depression Scale

The aim of this study was to determine the psychometric properties (especially validity and reliability) of the French language version of the Calgary Depression Scale for Schizophrenia (CDSS) in schizophrenic patients. Ninety-five subjects who met DSM-IV criteria for schizophrenia were enrolled. The studies of the internal structural validity and of the reliability (internal consistency) showed that some items from the CDSS (early awakening and guilty ideas of reference) must be discussed in the constitution of this scale. The total score of the CDSS was significantly correlated with the MADRS total score, the HDRS total score, and the depression item (G6) on the PANSS, which suggests that the CDSS is a valid instrument for the assessment of depression in schizophrenia. The existence of a significant correlation between the CDSS total score and the PANSS positive sub-scale suggests a possible relationship between positive and depressive symptoms in schizophrenia.

Depression in schizophrenia: I. Association with neuropsychological deficits

BACKGROUND

The presence of depression in schizophrenia has been well described with regard to stage and symptoms of illness; however, little is known about the possible etiology.

METHODS

In an effort to advance the understanding of the neurobiology of depression in schizophrenia, we grouped patients with schizophrenia based on their ratings on the 21-item Hamilton Depression Rating Scale. There were 63 patients (35 men, 28 women) in the high (> or = 18) depression group and 81 patients (52 men, 29 women) in the low (< 18) depression group. The groups were compared in demographic, clinical, and eight neuropsychological domains.

RESULTS

The two groups differed in age at onset of illness, severity of delusions, and performance in a single neuropsychological domain: attention. The specific component of impaired attention was vigilance, with poorest performance seen in women with higher depression scores.

CONCLUSION

The presence of specific attentional impairment associated with depressive symptoms in schizophrenia is consistent with the hypothesis of frontal lobe dysfunction in depression, because these regions have been implicated in attentional processes.

Depressive symptoms in acute schizophrenic inpatients

Prospective and longitudinal assessment of depressive, positive, and negative symptoms were performed on 86 newly admitted schizophrenic patients. The improvement of depressive symptoms was significantly correlated with the improvement in positive symptoms, but did not correlate with the improvement in negative symptoms. However, depressive symptoms were heterogeneous. Principal components analysis was used to subdivide depressive symptoms into five factors. The improvement of the depression-anxiety factor was significantly associated with improvement of positive symptoms. On the other hand, improvement of negative symptoms was significantly related to that of the reduced activity factor. The change in hypochondriasis had a significant positive correlation with the change in positive symptoms and had a significant negative correlation with the change in negative symptoms. Changes in the other factors of depressive symptoms did not appear to be associated with changes in positive or negative symptoms. The present findings suggest that the various depressive symptoms associated with acute schizophrenia may have different pathophysiological origins.

Construct validity of negative symptoms: an empirical and conceptual review

The construct validity of negative symptoms is reviewed, and findings on deficit negative symptoms are also incorporated. A valid negative symptom construct should: (a) have replicable relationships with observable phenomena and other constructs; (b) have good reliability, temporal stability, and homogeneity; and (c) predict prognosis and response to treatment, possess convergent and discriminant validity, and be useful to clinicians. Although a number of well-replicated findings provide support for the validity of the construct, modification is warranted. Specifically, the data suggest that there is a highly correlated set of negative symptoms, which includes flat affect, alogia, anhedonia, and avolition. Primary and enduring symptoms from this set have good predictive and discriminant validity and can be studied in the context of the deficit syndrome, as well as with current negative symptom rating scales. Future studies should examine whether deficit negative symptoms are better conceptualized as a dimension or a category, elucidate the relationship between deficit symptoms and additional clinical and behavioral variables (e.g., response to newer neuroleptic medications and diminished emotional responding), and explore differences between the pattern of correlates of deficit symptoms and those of the positive and thought disorder symptoms.

Treatment of negative symptoms in schizophrenia and schizoaffective disorder by selegiline augmentation of antipsychotic medication. A pilot study examining the role of dopamine

It has been suggested that schizophrenic negative symptoms may be manifestations of regionally deficient CNS dopaminergic activity. We sought to test this hypothesis by openly treating patients on chronic antipsychotic medication who showed prominent negative symptoms with low-dose selegiline (5 mg b.i.d.), a monoamine oxidase-B inhibitor that selectively enhances dopaminergic activity. Twenty-one patients meeting DSM-III-R criteria for chronic schizophrenia (N = 14) or schizoaffective disorder (N = 7) with prominent negative symptoms were studied. Subjects had been kept at their current antipsychotic and antiparkinsonian medication dose levels for at least a month before the study, which was continued unchanged throughout the trial. Over 6 weeks of selegiline treatment, a 34.7% reduction in negative symptoms was demonstrated on the Scale for the Assessment of Negative Symptoms. There were also reductions in depressive symptoms (21-item Hamilton Depression Scale dropped 36.8%) and extrapyramidal symptoms (Simpson-Angus Extrapyramidal Symptom Scale scores dropped 27.7%), but no change was observed in the severity of positive symptoms as measured by the Brief Psychiatric Rating Scale. Global clinical improvement was demonstrated, with mean Clinical Global Impressions Scale score rising 17.6%. These findings support the hypothesis that negative symptoms, as well as extrapyramidal symptoms and certain depressive symptoms, may be manifestations of regionally deficient dopaminergic activity.