Wartime changes in hospital admissions for schizophrenia. A comparison of admission for schizophrenia and other psychoses in six countries during World War II

Pilot study indicates that a gluten-free diet lowers oxidative stress for gluten-sensitive persons with schizophrenia

One-third of people with schizophrenia have elevated levels of anti-gliadin antibodies (AGA IgG). A 5-week randomized double-blind pilot study was performed in 2014-2017 in an inpatient setting to test the effect of a gluten-free diet (GFD) on participants with schizophrenia or schizoaffective disorder who also had elevated AGA IgG (≥ 20 U) but were negative for celiac disease. This earlier pilot study reported that the GFD-group showed improved gastrointestinal and psychiatric symptoms, and also improvements in TNF-α and the inflammatory cytokine IL-23. Here, we performed measurements of these banked plasma samples to detect levels of oxidative stress (OxSt) using a recently developed iridium (Ir)-reducing capacity assay. Triplicate measurements of these samples showed an Intraclass Correlation Coefficient of 0.84 which indicates good reproducibility. Further, a comparison of the OxSt measurements at the baseline and 5-week end-point for this small sample size shows that the GFD-group (N = 7) had lowered OxSt levels compared to the gluten-containing diet group (GCD; N = 9; p = 0.05). Finally, we showed that improvements in OxSt over these 5 weeks were correlated to improvements in gastrointestinal (r = +0.64, p = 0.0073) and psychiatric (r = +0.52, p = 0.039) symptoms. Also, we showed a possible association between the decrease in OxSt and the lowered levels of IL-23 (r = +0.44, p = 0.087), although without statistical significance. Thus, the Ir-reducing capacity assay provides a simple, objective measure of OxSt with the results providing further evidence that inflammation, redox dysregulation and OxSt may mediate interactions between the gut and brain.

Psychiatric ward admissions during the COVID-19 pandemic in Canton of Ticino (Swiss Confederation) and the province of Como (Italy): a comparison between two different systems of care and outbreak response strategies

The aim of the study was to estimate the effect of the COVID- 19 pandemic and response policies on the psychiatric ward admissions in the hospitals referring to the ASST Lariana (province of Como, Italy) and the Hospital of Mendrisio (Canton of Ticino, Switzerland), two similar territories that belong to countries that dealt differently with the pandemic. We compared the two territories for type of admission (voluntary vs. compulsory), the Stringency Index (SI) and the country’s number of admission in Intensive Care Units (ICU). We found a significant reduction in the psychiatric ward admission in the lockdown period in both territories, even in periods with milder lockdown measures. The admission rate’s reduction in the ASST Lariana was significantly associated with the ICU admissions (p<0.001). In the Hospital of Mendrisio, admissions included a weekly seasonality, were significantly correlated with SI (p=0.001) and period (pre-pandemic and pandemic; p<0.001) and we observed also a significant reduction of compulsory admission that is influenced both by the stringency index (p<0.001) and period (p<0.001). The differences between the two territories seem influenced by the different mental health systems.

Unhealthy diet in schizophrenia spectrum disorders

PURPOSE OF REVIEW

The high mortality and prevalence of metabolic syndrome in patients with schizophrenia spectrum disorders (SSD) is maintained by poor diet. This narrative review summarizes recent literature to provide a reflection of current eating habits, dietary preferences, and nutritional status of SSD patients. Elucidating these factors provides new insights for potential lifestyle treatment strategies for SSD.

RECENT FINDINGS

Only 10.7% of the SSD patients had a healthy dietary pattern, against 23% of the general population. The dietic component of the Keeping the Body in Mind Xtend lifestyle program increased diet quality with 10% for young people with first-episode psychosis, compared to baseline, which was predominantly driven by increased vegetable variety and amounts.

SUMMARY

Recent findings render poor dietary habits as potential targets for treatment of SSD patients. Further studies into anti-inflammatory diets and associations with gut-brain biomarkers are warranted. When proven, structured and supervised diet interventions may help SSD patients escape from this entrapment, as only supplementing nutrients or providing dietary advice lacks the impact to significantly reduce the risk of chronic physical illnesses.

Effects of lockdown on emergency room admissions for psychiatric evaluation: an observational study from the AUSL Romagna, Italy

OBJECTIVES

An observation of the admissions to the emergency room (ER) requiring psychiatric evaluation during the lockdown and investigation of the demographic and clinical variables.

METHODS

Retrospective longitudinal observational study of ER accesses for psychiatric evaluation was performed, comparing two periods (9 March-3 May 2020 vs. 9 March-3 May 2019). Data (number of admissions, key baseline demographic and clinical variables) were extracted from the ER databases of referral centres in a well-defined geographic area of North-Eastern Italy (Cesena, Ravenna, Forlì, and Rimini).

RESULTS

A 15% reduction of psychiatric referrals was observed, together with a 17% reduction in the total number of patients referring to the ER. This reduction was most evident in the first month of the lockdown period (almost 25% reduction of both referrals and patients). Female gender (OR: 1.52: 95%, CI: 1.12-2.06) and being a local resident (OR: 1.54: 95%CI: 1.02-2.34) were factors associated with the decrease.

CONCLUSIONS

Lockdown changed dramatically health priorities in the local population, including people with mental health. We speculate that our observations do not only refer to the confinement due to the lockdown regime but also to fear of contagion and adoption of different coping strategies, especially in women.Key-pointsDuring lockdown 15% reduction of psychiatric visits and >17% reduction in the number of psychiatric patients referring to the ER was observed.in the first four weeks of the lockdown almost 25% reduction of both visits and patients was observedFemale gender and being a local resident were factors associated with the decrease.

Diet and Psychosis: A Scoping Review

INTRODUCTION

Schizophrenia spectrum disorders (SSD) represent a cluster of severe mental illnesses. Diet has been identified as a modifiable risk factor and opportunity for intervention in many physical illnesses and more recently in mental illnesses such as unipolar depression; however, no dietary guidelines exist for patients with SSD.

OBJECTIVE

This review sought to systematically scope the existing literature in order to identify nutritional interventions for the prevention or treatment of mental health symptoms in SSD as well as gaps and opportunities for further research.

METHODS

This review followed established methodological approaches for scoping reviews including an extensive a priori search strategy and duplicate screening. Because of the large volume of results, an online program (Abstrackr) was used for screening and tagging. Data were extracted based on the dietary constituents and analyzed.

RESULTS

Of 55,330 results identified by the search, 822 studies met the criteria for inclusion. Observational evidence shows a connection between the presence of psychotic disorders and poorer quality dietary patterns, higher intake of refined carbohydrates and total fat, and lower intake or levels of fibre, ω-3 and ω-6 fatty acids, vegetables, fruit, and certain vitamins and minerals (vitamin B12 and B6, folate, vitamin C, zinc, and selenium). Evidence illustrates a role of food allergy and sensitivity as well as microbiome composition and specific phytonutrients (such as L-theanine, sulforaphane, and resveratrol). Experimental studies have demonstrated benefit using healthy diet patterns and specific vitamins and minerals (vitamin B12 and B6, folate, and zinc) and amino acids (serine, lysine, glycine, and tryptophan).

DISCUSSION

Overall, these findings were consistent with many other bodies of knowledge about healthy dietary patterns. Many limitations exist related to the design of the individual studies and the ability to extrapolate the results of studies using dietary supplements to dietary interventions (food). Dietary recommendations are presented as well as recommendations for further research including more prospective observational studies and intervention studies that modify diet constituents or entire dietary patterns with statistical power to detect mental health outcomes.

Psychiatric hospitalization rates in Italy before and during COVID-19: did they change? An analysis of register data

OBJECTIVES.

To assess admission rates to seven General Hospital Psychiatric Wards (GHPWs) located in the Lombardy Region in the 40 days after the start of Coronavirus disease 2019 (COVID-19) epidemic, compared to similar periods of 2020 and 2019.

METHODS.

Anonymized data from the regional psychiatric care register have been obtained and analyzed. The seven GHPWs care for approximately 1.4 million inhabitants and have a total of 119 beds.

RESULTS.

In the 40-day period (February 21-March 31, 2020) after the start of the COVID-19 epidemic in Italy, compared to a similar 40-day period prior to February 21, and compared to two 40-day periods of 2019, there has been a marked reduction in psychiatric admission rates. The reduction was explained by voluntary admissions, while there was not a noticeable reduction for involuntary admissions. The reduction was visible for all diagnostic groups, except for a group of 'Other' diagnoses, which includes anxiety disorders, neurocognitive disorders, etc.

CONCLUSIONS.

Large-scale pandemics can modify voluntary admission rates to psychiatric facilities in the early phases following pandemic onset. We suggest that the reduction in admission rates may be due to fear of hospitals, seen as possible sites of contagion, as well as to a change in thresholds of behavioral problems acting as a trigger for admission requests from family relatives or referrals from treating clinicians. It is unclear from the study whether the reduction in admissions was contributed to most by the current pandemic or the lockdown imposed due to the pandemic.

Randomized controlled trial of a gluten-free diet in patients with schizophrenia positive for antigliadin antibodies (AGA IgG): a pilot feasibility study

BACKGROUND

Approximately one-third of people with schizophrenia have elevated levels of anti-gliadin antibodies of the immunoglobulin G type (AGA IgG) — a higher rate than seen in healthy controls. We performed the first double-blind clinical trial of gluten-free versus gluten-containing diets in a subset of patients with schizophrenia who were positive for AGA IgG.

METHODS

In this pilot feasibility study, 16 participants with schizophrenia or schizoaffective disorder who had elevated AGA IgG (≥ 20 U) but were negative for celiac disease were admitted to an inpatient unit for a 5-week trial. All participants received standardized gluten-free meals and were randomized in a double-blind fashion to receive a shake containing 10 g of gluten flour or 10 g of rice flour each day. Participants were rated for psychiatric, cognitive and gastrointestinal symptoms at baseline and endpoint.

RESULTS

Of the 16 participants, 14 completed the 5-week trial (2 discontinued early for administrative reasons). Compared with participants on the gluten-containing diet, participants on the gluten-free diet showed improvement on the Clinical Global Impressions scale (Cohen d = –0.75) and in negative symptoms (Cohen d = –0.53). We noted no improvement in positive or global cognitive symptoms, but did observe an improvement in attention favouring the gluten-free diet (Cohen d = 0.60). Robust improvements in gastrointestinal adverse effects occurred in the gluten-free group relative to the glutencontaining group. Adverse effects were similar between groups.

LIMITATIONS

This study was limited by its small sample size; larger studies are needed.

CONCLUSION

This feasibility study suggests that removal of gluten from the diet is associated with improvement in psychiatric and gastrointestinal symptoms in people with schizophrenia or schizoaffective disorder.

Autoimmune phenotypes in schizophrenia reveal novel treatment targets

Typical and atypical antipsychotics are the first-line treatments for schizophrenia, but these classes of drugs are not universally effective, and they can have serious side effects that impact compliance. Antipsychotic drugs generally target the dopamine pathways with some variation. As research of schizophrenia pathophysiology has shifted away from a strictly dopamine-centric focus, the development of new pharmacotherapies has waned. A field of inquiry with centuries-old roots is gaining traction in psychiatric research circles and may represent a new frontier for drug discovery in schizophrenia. At the forefront of this investigative effort is the immune system and its many components, pathways and phenotypes, which are now known to actively engage the brain. Studies in schizophrenia reveal an intricate association of environmentally-driven immune activation in concert with a disrupted genetic template. A consistent conduit through this gene-environmental milieu is the gut-brain axis, which when dysregulated can generate pathological autoimmunity. In this review, we present epidemiological and biochemical evidence in support of an autoimmune component in schizophrenia and depict gut processes and a dysbiotic microbiome as a source and perpetuator of autoimmune dysfunction in the brain. Within this framework, we review the role of infectious agents, inflammation, gut dysbioses and autoantibody propagation on CNS pathologies such as neurotransmitter receptor hypofunction and complement pathway-mediated synaptic pruning. We then review the new pharmacotherapeutic horizon and novel agents directed to impact these pathological conditions. At the core of this discourse is the understanding that schizophrenia is etiologically and pathophysiologically heterogeneous and thus its treatment requires individualized attention with disease state variants diagnosed with objective biomarkers.

Gluten related illnesses and severe mental disorders: a comprehensive review

The putative role of gluten in the pathophysiology of severe mental illnesses remains uncertain and there is doubt about the possible benefit of gluten-free diets for individuals affected by psychosis and mood disorders. The objective of this review was to summarize the findings linking gluten related conditions to pathophysiological substrates implicated in schizophrenia and mood disorders and review the evidences of potential benefits of glute-free diets in these populations. A literature search was conducted within PubMed and Scielo databases including references from inception until March 1st 2017. The strategy search was to use the key words "gluten", "celiac disease", "wheat", "bipolar disorder", "mood disorders", "psychosis", "schizophrenia", "depression". In the review about the potential efficacy of gluten-free diets in severe mental illnesses, we included only studies with original data, including cross sectional and longitudinal studies and clinical trials. Book chapters, review articles and meta-analysis and republished data were excluded. Although the current available evidences suggest that people with celiac disease or gluten allergy could have a slightly higher risk of schizophrenia and mood disorders compared to the general population, the literature review reveals significant inaccuracies in the data. There is insufficient evidence to recommend gluten-free diets for populations with psychosis and mood disorders.

A review on the relationship between gluten and schizophrenia: Is gluten the cause?

INTRODUCTION

Schizophrenia is a chronic disease that possesses various clinical manifestations. It presents rather heterogeneous characteristics with respect to onset type, symptoms, and the course of the disease. Although the lifetime prevalence is as low as 1%, it can cause serious disability. Thus, it is very important to develop efficient treatment methods. In some studies, it is hypothesized that removing gluten from the diet leads to a significant improvement in disease symptoms. Epidemiological studies revealed that the prevalence of celiac disease among schizophrenic patients is almost two times higher than that of the general population.

OBJECTIVE

In this review, we evaluate the effects of gluten and celiac disease on the onset of schizophrenia. Efficacy of gluten-free diet applications, antibody response against gluten, and the interaction of the brain-gut axis and the presence of common genetic points are also investigated.

METHODS

Without any publication date restriction, Pubmed database searches were made for 'schizophrenia, gluten, gliadin, celiac disease, exorphin, brain-gut axis, psychiatric disorders.' The keywords and the articles about the schizophrenia-celiac disease relationship are included in our review.

RESULTS

Several studies presented evidence to suggest that symptoms associated with schizophrenia were minimized when gluten was excluded from patients' diets. Immunological searches revealed that most schizophrenic patients with increased anti-gliadin antibodies did not possess celiac disease; yet, the presence of increased antibodies against gliadin can be the share point of the immunological abnormalities found in both of the diseases.

DISCUSSION

There were no consistent results in the clinical, immunological, microbiological, and epidemiological studies that investigated the relationship between schizophrenia and celiac disease. This presents a need for a larger scale study to confirm the presence of this suggested correlation between schizophrenia and celiac disease. The underlying mechanisms between the two diseases should be explored.

Autoimmune diseases, gastrointestinal disorders and the microbiome in schizophrenia: more than a gut feeling

Autoimmunity, gastrointestinal (GI) disorders and schizophrenia have been associated with one another for a long time. This paper reviews these connections and provides a context by which multiple risk factors for schizophrenia may be related. Epidemiological studies strongly link schizophrenia with autoimmune disorders including enteropathic celiac disease. Exposure to wheat gluten and bovine milk casein also contribute to non-celiac food sensitivities in susceptible individuals. Co-morbid GI inflammation accompanies humoral immunity to food antigens, occurs early during the course of schizophrenia and appears to be independent from antipsychotic-generated motility effects. This inflammation impacts endothelial barrier permeability and can precipitate translocation of gut bacteria into systemic circulation. Infection by the neurotropic gut pathogen, Toxoplasma gondii, will elicit an inflammatory GI environment. Such processes trigger innate immunity, including activation of complement C1q, which also functions at synapses in the brain. The emerging field of microbiome research lies at the center of these interactions with evidence that the abundance and diversity of resident gut microbiota contribute to digestion, inflammation, gut permeability and behavior. Dietary modifications of core bacterial compositions may explain inefficient gluten digestion and how immigrant status in certain situations is a risk factor for schizophrenia. Gut microbiome research in schizophrenia is in its infancy, but data in related fields suggest disease-associated altered phylogenetic compositions. In summary, this review surveys associative and experimental data linking autoimmunity, GI activity and schizophrenia, and proposes that understanding of disrupted biological pathways outside of the brain can lend valuable information regarding pathogeneses of complex, polygenic brain disorders.

Bread and Other Edible Agents of Mental Disease

Perhaps because gastroenterology, immunology, toxicology, and the nutrition and agricultural sciences are outside of their competence and responsibility, psychologists and psychiatrists typically fail to appreciate the impact that food can have on their patients' condition. Here we attempt to help correct this situation by reviewing, in non-technical, plain English, how cereal grains-the world's most abundant food source-can affect human behavior and mental health. We present the implications for the psychological sciences of the findings that, in all of us, bread (1) makes the gut more permeable and can thus encourage the migration of food particles to sites where they are not expected, prompting the immune system to attack both these particles and brain-relevant substances that resemble them, and (2) releases opioid-like compounds, capable of causing mental derangement if they make it to the brain. A grain-free diet, although difficult to maintain (especially for those that need it the most), could improve the mental health of many and be a complete cure for others.

Unipolar mania: a necessary diagnostic concept

In the classification of mood disorders, major depressive disorder is separate from bipolar disorders whereas mania is not. Studies on pure mania are therefore rare. Our paper reviews the evidence for distinguishing pure mania (M) and mania with mild depression (Md) from bipolar disorder. Two large epidemiological studies found a prevalence of 1.7-1.8% of M/Md in adolescents and adults. Several clinical follow-up studies demonstrated good stability of the diagnosis after a previous history of three manic episodes. Compared to bipolar disorder, manic disorder is characterised by a weaker family history for depression, an earlier onset, fewer recurrences and better remission, and is less comorbid with anxiety disorders. In addition, mania is strongly associated with a hyperthymic temperament, manifests more psychotic symptoms and is more often treated with antipsychotics. Twin and family studies find mania to be more heritable than depression and show no significant transmission from depression to mania or from mania to depression. Cardiovascular mortality is elevated among patients with mood disorders generally and is highest among those with mania. In non-Western countries, mania and the manic episodes in bipolar disorder are reported to occur more frequently than in Western countries.

Gastroenterology issues in schizophrenia: why the gut matters

Genetic and environmental studies implicate immune pathologies in schizophrenia. The body's largest immune organ is the gastrointestinal (GI) tract. Historical associations of GI conditions with mental illnesses predate the introduction of antipsychotics. Current studies of antipsychotic-naïve patients support that gut dysfunction may be inherent to the schizophrenia disease process. Risk factors for schizophrenia (inflammation, food intolerances, Toxoplasma gondii exposure, cellular barrier defects) are part of biological pathways that intersect those operant in the gut. Central to GI function is a homeostatic microbial community, and early reports show that it is disrupted in schizophrenia. Bioactive and toxic products derived from digestion and microbial dysbiosis activate adaptive and innate immunity. Complement C1q, a brain-active systemic immune component, interacts with gut-related schizophrenia risk factors in clinical and experimental animal models. With accumulating evidence supporting newly discovered gut-brain physiological pathways, treatments to ameliorate brain symptoms of schizophrenia should be supplemented with therapies to correct GI dysfunction.

IgG dynamics of dietary antigens point to cerebrospinal fluid barrier or flow dysfunction in first-episode schizophrenia

Schizophrenia is a complex brain disorder that may be accompanied by idiopathic inflammation. Classic central nervous system (CNS) inflammatory disorders such as viral encephalitis or multiple sclerosis can be characterized by incongruent serum and cerebrospinal fluid (CSF) IgG due in part to localized intrathecal synthesis of antibodies. The dietary antigens, wheat gluten and bovine milk casein, can induce a humoral immune response in susceptible individuals with schizophrenia, but the correlation between the food-derived serological and intrathecal IgG response is not known. Here, we measured IgG to wheat gluten and bovine milk casein in matched serum and CSF samples from 105 individuals with first-episode schizophrenia (n=75 antipsychotic-naïve), and 61 controls. We found striking correlations in the levels of IgG response to dietary proteins between serum and CSF of schizophrenia patients, but not controls (schizophrenia, R(2)=0.34-0.55, p⩽0.0001; controls R(2)=0.05-0.06, p>0.33). A gauge of blood-CSF barrier permeability and CSF flow rate, the CSF-to-serum albumin ratio, was significantly elevated in cases compared to controls (p⩽0.001-0.003). Indicators of intrathecal IgG production, the CSF IgG index and the specific Antibody Index, were not significantly altered in schizophrenia compared to controls. Thus, the selective diffusion of bovine milk casein and wheat gluten antibodies between serum and CSF in schizophrenia may be the function of a low-level anatomical barrier dysfunction or altered CSF flow rate, which may be transient in nature.

Seroreactive marker for inflammatory bowel disease and associations with antibodies to dietary proteins in bipolar disorder

OBJECTIVES

Immune sensitivity to wheat glutens and bovine milk caseins may affect a subset of individuals with bipolar disorder. Digested byproducts of these foods are exorphins that have the potential to impact brain physiology through action at opioid receptors. Inflammation in the gastrointestinal (GI) tract might accelerate exposure of food antigens to systemic circulation and help explain elevated gluten and casein antibody levels in individuals with bipolar disorder.

METHODS

We measured a marker of GI inflammation, anti-Saccharomyces cerevisiae antibodies (ASCA), in non-psychiatric controls (n = 207), in patients with bipolar disorder without a recent onset of psychosis (n = 226), and in patients with bipolar disorder with a recent onset of psychosis (n = 38). We compared ASCA levels to antibodies against gluten, casein, Epstein-Barr virus (EBV), herpes simplex virus 1 (HSV-1), influenza A, influenza B, measles, and Toxoplasma gondii.

RESULTS

Elevated ASCA conferred a 3.5-4.4-fold increased odds ratio of disease association (age-, race-, and gender-corrected multinomial logistic regressions, p ≤ 0.00001) that was independent of type of medication received. ASCA correlated with food antibodies in both bipolar disorder groups (R(2)  = 0.29-0.59, p ≤ 0.0005), and with measles and T. gondii immunoglobulin G (IgG) in the recent onset psychosis bipolar disorder group (R(2)  = 0.31-0.36, p ≤ 0.004-0.01).

CONCLUSIONS

Elevated seropositivity of a GI-related marker and its association with antibodies to food-derived proteins and self-reported GI symptoms suggest a GI comorbidity in at least a subgroup of individuals with bipolar disorder. Marker seroreactivity may also represent part of an overall heightened activated immune state inherent to this mood disorder.

Discordant patterns of bacterial translocation markers and implications for innate immune imbalances in schizophrenia

The origin of inflammation in psychiatric disorders is not well understood. The translocation of commensal microbiota across the gastrointestinal barrier can result in a persistent state of low-grade immune activation and/or inflammation. We measured serological surrogate markers of bacterial translocation (soluble CD14 (sCD14) and lipopolysaccharide binding protein (LBP)) in two psychiatric cohorts and compared these levels to C-reactive protein (CRP), body mass index (BMI), and food-related and autoimmune antibodies. The two cohorts were composed of the following: (1) n=141 schizophrenia, n=75 bipolar disorder, n=78 controls; (2) n=78 antipsychotic-naïve first-episode schizophrenia, n=38 medicated first-episode schizophrenia. sCD14 seropositivity conferred a 3.1-fold increased odds of association with schizophrenia (multivariate regressions, OR=3.09, p<0.0001) compared to controls. Case-control differences in sCD14 were not matched by LBP. Quantitative levels of LBP, but not sCD14, correlated with BMI in schizophrenia (R(2)=0.21, p<0.0001). sCD14 and LBP also exhibited some congruency in schizophrenia with both significantly correlated with CRP (R(2)=0.26-0.27, p<0.0001) and elevated in females compared to males (p<0.01). Antipsychotic treatment generally did not impact sCD14 or LBP levels except for significant correlations, especially sCD14, with gluten antibodies in antipsychotic-naïve schizophrenia (R(2)=0.27, p<0.0001). In bipolar disorder, sCD14 levels were significantly correlated with anti-tissue transglutaminase IgG (R(2)=0.37, p<0.001). In conclusion, these bacterial translocation markers produced discordant and complex patterns of activity, a finding that may reflect an imbalanced, activated innate immune state. Whereas both markers may upregulate following systemic exposure to Gram-negative bacteria, non-lipopolysaccharide-based monocyte activation, autoimmunity and metabolic dysfunction may also contribute to the observed marker profiles.

No association observed between schizophrenia and non-HLA coeliac disease genes: integration with the initial MYO9B association with coeliac disease

Schizophrenia is a severe psychotic illness with a heterogeneous presentation and a devastating impact on social and occupational function. Worldwide variations in schizophrenia incidence rates suggest that local conditions may modify disease risk. The human leukocyte antigen (HLA) region has been confirmed to be associated with schizophrenia by genome-wide association studies in populations across the world. While the presence of autoimmune processes in a subgroup of schizophrenia cases is contentious, the immune system could allow environmental exposures to lead to schizophrenia by generating improper immune response. To investigate this topic, we reviewed the current evidence of the relationship between schizophrenia and coeliac disease. Based on this review, we performed genetic analysis of the MYO9B gene and the IL-2/IL-21 locus by genotyping SNPs that have been previously associated with coeliac disease or schizophrenia in 223 families, 108 unrelated individuals with schizophrenia and 120 controls. Finding no evidence for association with these two loci in our study samples, we applied meta-analytic techniques to combine our findings with previous reports. This synthesis, in light of our review of previous reports, suggests a differing developmental trajectory for schizophrenia and coeliac disease. It is possible that these two conditions do not share any functional overlap.

Diagnosis and course of affective psychoses: was Kraepelin right?

Kraepelin's basic attitude to the classification of psychoses was data-oriented and flexible. In his latter years he was close to revising his own celebrated dichotomy between manic-depressive insanity and dementia praecox in order to take account of a large group of intermediate psychoses, which today are called schizo-affective. His concept of a continuum from healthy to ill has stood the test of time and corresponds to modern epidemiological findings. Kraepelin's unitarian concept of manic-depressive insanity did not survive. It was differentiated and broken down into several subgroups, and a proportional diagnostic spectrum with a continuum from mania via bipolar disorders to depression has recently even been proposed. Bipolar disorders would in that case be comorbid disorders of mania plus depression. In contrast to Kraepelin's unitarian view the long-term prognosis of subgroups of mood disorders varies considerably. Overall it is nevertheless astonishing how much of Kraepelin's legacy has survived.

Is MYO9B the missing link between schizophrenia and celiac disease?

There has long been discussion on the correlation between schizophrenia and autoimmune diseases (especially celiac disease), which makes the recently discovered celiac disease risk factor, MYO9B, an attractive functional and positional candidate gene for schizophrenia. To test this hypothesis we compared allele frequencies of three MYO9B tag SNPs in 315 schizophrenia cases and 1,624 healthy controls in a genetic association study. Highly significant differences in allele frequencies between schizophrenia cases and healthy controls were observed for SNP rs2305767 in intron 14 of MYO9B (P = 1.16 x 10(-4); OR 1.41, 95% CI 1.18-1.67). We demonstrate significant association of allelic variants in MYO9B with schizophrenia. To our knowledge, this is the first molecular genetic evidence for a correlation between autoimmune diseases and the risk of developing schizophrenia.

Bipolar depression: diagnostic and treatment considerations

Bipolar affective disorder is a recurrent, disabling, and potentially lethal illness that typically begins early in life. Although the disorder is defined by the manic and hypomanic episodes, for most people the depression episodes are the more virulent aspect of the illness. Specifically, the depressive episodes are more numerous, last longer, and are more difficult to treat than the manias, and depression is the principal cause of the illness's increased mortality due to suicide. For people with early-onset depression, predictors of subsequent bipolarity include a family history, psychotic features, and reverse neurovegetative features. Initial episodes of depression are commonly misdiagnosed, which often delays initiation of appropriate therapy and increases the likelihood of treatment with antidepressants alone. Unfortunately, the correct diagnosis is often not made until there has been a treatment-emergent affective switch. There are no treatments specifically approved for bipolar disorder in youth and, among antidepressants, only fluoxetine has received approved. When bipolarity is suspected, treatment with mood stabilizers, both conventional (i.e., lithium, valproate, and carbamazapine) and more recently classified (lamotrigine) and atypical antipsychotics should be prioritized. When antidepressants are indicated in combination with mood stabilizers, first choice options include bupropion and the selective serotonin reuptake inhibitors. Studies of adults indicate that several forms of focused psychotherapy may improve longer term outcomes.

The gluten connection: the association between schizophrenia and celiac disease

OBJECTIVE

Schizophrenia affects roughly 1% of the population and is considered one of the top 10 causes of disability worldwide. Given the immense cost to society, successful treatment options are imperative. Based on initial findings, gluten withdrawal may serve as a safe and economical alternative for the reduction of symptoms in a subset of patients.

METHOD

A review of the literature relevant to the association between schizophrenia and celiac disease (gluten intolerance) was conducted.

RESULTS

A drastic reduction, if not full remission, of schizophrenic symptoms after initiation of gluten withdrawal has been noted in a variety of studies. However, this occurs only in a subset of schizophrenic patients.

CONCLUSION

Large-scale epidemiological studies and clinical trials are needed to confirm the association between gluten and schizophrenia, and address the underlying mechanisms by which this association occurs.

Observing relationships in Finnish adoptive families: Oulu Family Rating Scale

Adoption studies were intended to separate genetic from environmental "causal" factors. In earlier adoption studies, psychiatric diagnostic labels for the adoptive parents were used as a proxy for the multiple dimensions of the family rearing environment. In the Finnish Adoption Study, research design provided the opportunity to study directly the adoptive family rearing environment. For this purpose 33 sub-scales were selected creating what we call Oulu Family Rating Scale (OPAS, Oulun PerheArviointiSkaala). In this paper, the manual for scoring of these sub-scales is presented.

Bipolar depression: phenomenological overview and clinical characteristics

OBJECTIVES

There has been increasing interest in the depressed phase of bipolar disorder (bipolar depression). This paper aims to review the clinical characteristics of bipolar depression, focusing upon its prevalence and phenomenology, related neuropsychological dysfunction, suicidal behaviour, disability and treatment responsiveness.

METHODS

Studies on the prevalence of depression in bipolar disorder, the comparative phenomenology of bipolar and unipolar depression, as well as neuropsychology and brain imaging studies, are reviewed. To identify relevant papers, a literature search using MEDLINE and PubMed was undertaken.

RESULTS

Depression is the predominant mood disturbance in bipolar disorder, and most frequently presents as subsyndromal, minor or dysthymic depression. Compared with major depressive disorder (unipolar depression), bipolar depression is more likely to manifest with psychosis, melancholic symptoms, psychomotor retardation (in bipolar I disorder) and 'atypical' symptoms. The few neuropsychological studies undertaken indicate greater impairment in bipolar depression. Suicide rates are high in bipolar disorder, with suicidal ideation, suicide attempts and completed suicides all occurring predominantly in the depressed phase of this condition. Furthermore, the depressed phase (even subsyndromal) appears to be the major contributant to the disability related to this condition.

CONCLUSIONS

The significance of the depressed phase of bipolar disorder has been markedly underestimated. Bipolar depression accounts for most of the morbidity and mortality due to this illness. Current treatments have significant limitations.

Bipolar depression: management options

Bipolar depression is the predominant abnormal mood state in bipolar disorder. However, despite the key pertinence of this phase of the condition, the focus of research and indeed of clinical interest in the management of bipolar disorder has been mainly on mania. Bipolar depression has been largely neglected, and early studies often failed to distinguish depression due to major unipolar depression from that due to bipolar disorder. Consequently, many treatments used in the management of major depression have been adopted for use in bipolar depression without any robust evidence of efficacy. The selective serotonin reuptake inhibitors (SSRIs), bupropion, tricyclic antidepressants and monoamine oxidase inhibitors are all effective antidepressants in the management of bipolar depression. They are all associated with a small risk of antidepressant-induced mood instability. The mood stabilisers lithium, carbamazepine and valproate semisodium (divalproex sodium) all appear to have modest acute antidepressant properties. Among these, lithium is supported by the strongest data, but the use of lithium in the treatment of bipolar depression as a monotherapeutic agent is limited by its slow onset of action. Recently, there has been a growing body of evidence suggesting that lamotrigine may have particular effectiveness in both the acute and prophylactic management of bipolar depression. Clinical management of bipolar depression involves various combinations of antidepressants and mood stabilisers and is partly determined by the context in which the depressive episode occurs. In general, 'de novo' and 'breakthrough' (where the patient is already receiving medication) bipolar depression may be successfully managed by initiating mood stabiliser monotherapy, to which an antidepressant or second mood stabiliser may be added at a later date, if necessary. Breakthrough episodes of bipolar depression occurring in patients receiving combination therapy (two mood stabilisers or a mood stabiliser plus an antidepressant) require either switching of ongoing medications or further augmentation. If this fails, then novel strategies or ECT should be considered. Bipolar depression is a disabling illness and the predominant mood state for the vast majority of those with bipolar disorder. It therefore warrants prompt management once suitably diagnosed, especially as it is associated with a considerable risk of suicide and in the majority of instances is eminently treatable.

Mood Disorder Service Genetic Database: morbidity risks for mood disorders in 3,942 first-degree relatives of 671 index cases with single depression, recurrent depression, bipolar I, or bipolar II

There is increasing evidence that genetic factors play a role in the etiology of mood disorders. As a result, relatives of affected individuals are more often asking about their own risks to develop a mood disorder. From 1988 to 1990, all consecutive, unrelated inpatients and outpatients (index cases) presenting to the Mood Disorders Service, Department of Psychiatry, University of British Columbia, had detailed family histories taken, thus creating the Mood Disorders Service Genetic Database. Diagnoses for index cases and their first-degree relatives were made according to Research Diagnostic Criteria and Family History Research Diagnostic Criteria respectively. Morbidity risks for mood disorders were calculated for first-degree relatives (parents, siblings, children--aged 10 and above) of all index cases with a diagnosis of single depression, recurrent depression, bipolar I, or bipolar II disorder. Morbidity risks were calculated using the maximum likelihood approach. Morbidity risk data are presented according to the sex and diagnosis for the index case in an easy reference format for risk counselling. The risks are presented twice, including and excluding data for "high-risk" families whose genetic pedigree is suggestive of "autosomal dominant" inheritance.

The genetics of bipolar disorder

Growing interest in the application of molecular biological techniques to psychiatric disorders has reinvigorated interest in the genetics of the psychoses. It is therefore timely to review the current state of knowledge of the genetics of bipolar disorder. Family, twin and adoption studies are all consistent in confirming the strongly heritable nature of this condition. As segregation analyses have been unable to determine the mode of transmission of bipolar disorder, ongoing linkage analyses using DNA markers will be crucial in determining whether this condition is due to a single major gene, a small number of genes, or multifactorial polygenic inheritance.

Psychiatric aspects of terrorist violence: Northern Ireland 1969-1987

For 18 years, Northern Ireland has suffered a changing pattern of civil disorder. Early years were marked by widespread sectarian rioting, shootings, and bombings, which heightened community tension and caused much social and commercial disruption. However, in recent years, terrorist organisations have been more selective in their acts of violence. There are methodological difficulties in assessing the psychological impact of civil disorder and terrorism. But, as well as can be judged from community surveys, hospital admissions and referral data, psychotropic drug usage, suicide and attempted suicide rates, and from assessment of the actual victims of violence, society has not 'broken down' nor has the impact been judged considerable. Possible explanations are discussed.

A double-blind gluten-free/gluten-load controlled trial in a secure ward population

A double-blind control trial of gluten-free versus a gluten-containing diet was carried out in a ward of maximum security hospital: 24 patients were studied for 14 weeks. Most suffered from psychotic disorders, particularly schizophrenia. Various dimensions of behaviour were rated on the Psychotic In-Patient profile (PIP) at different stages. There were beneficial changes in the whole group of patients between pre-trial and gluten-free period in five dimensions of the PIP, maintained during the gluten challenge period; these changes could be attributed to the attention the patients received. Two patients improved during the gluten-free period and relapsed when the gluten diet was reintroduced.

Food antibodies in acute psychoses

Antibodies to a variety of foods, and in particular cereals, were measured in serum from 100 patients with acute psychoses and 100 elective surgical patients. For 13 out of 14 foods to which non-IgE antibodies were detected the schizophrenics had slightly more antibodies than the controls. There was an association between a possible secondary mania and the presence of IgE antibodies to wheat or rye. However, neither the schizophrenia nor the mania findings can be regarded as evidence for food allergy causing psychiatric disorder, since the immunological findings in both cases may represent consequences of the illnesses or their treatment, rather than causes of the illness.

Food antibodies in schizophrenia

This study investigates the validity of the suggestion that food allergy is relevant to the manifestation of schizophrenic illness. Antibodies to oats, wheat, gluten, chicken, calf and milk protein were measured in 98 schizophrenics and in 90 unaffected close blood relatives. The majority of patients were male out-patients, and most were on neuroleptic medication. Antibodies were detected in only a minority of patients.

The dominant diseases of modernized societies as omega-3 essential fatty acid deficiency syndrome: substrate beriberi

About 1900, modern food selection and processing caused widespread epidemics of the B vitamin deficiency diseases of beriberi and pellagra which, for genetic reasons, often expressed as different diseases ranging from bowel and heart disease to dermatoses and psychoses. But the B vitamins merely help convert essential fatty acids (EFA) into the prostaglandin (PG) tissue regulators and it now turns out that, through hydrogenation, milling and selection of w3-poor southern foods, we have also been systematically depleting, by as much as 90%, a newly discovered trace Nordic EFA (w3) of special importance to primates and sole precursor of the PG3(4) series, even as a concurrent fiber deficiency increases body demand for EFA. Since substrate EFA is processed by many B vitamin catalysts, an EFA deficiency will mimic a panhypovitaminosis B, i.e., a mixture of substrate beriberi and substrate pellagra resembling vitamin beriberi and pellagra but exhibiting as even more diverse endemic disease. This would constitute a second stage of the Modern Malnutrition and explain why some workers now hold the dominant diseases of modernized societies to be new, nutritionally based, pellagraform yet lipid-related and to range, once again, from heart disease to psychosis. It is an assumption that our dominant diseases are unrelated to each other or are merely revealed by out diagnostic acumen and therapeutic success; and that hydrogenating millions of tons of food oils annually, to destroy the rancidity producing w30EFA, is safe for primates. Extensive beriberiform disease is reported here in 32 typical cases taken from medical practice which responds strikingly to linseed oil supplements (60% w3-EFA) in confirmation of identical results in Capuchins.

Diet (gluten) and schizophrenia

Four aspects of clinical evidence for an association between gluten and schizophrenia are examined. The scientific evidence for the role of gluten is set out. Finally, reference is made to other dietary approaches.

Psychiatric sequelae to a civil disturbance

On 13 May 1969, intercommunal rioting broke out between the Malay and Chinese sections of the population of Kuala Lumpur and continued for a full week. Subsequently a state of emergency was proclaimed, parliamentary government was suspended and the country was placed under the rule of the National Operations Council (a council of top ministers, civil servants and the chiefs of the armed forces and police) which ruled by edict.

The cost of commotion: an analysis of the psychiatric sequelae of the 1969 Belfast riots

The 1969 disturbances in Belfast were on a scale unprecedented since 1886. By the end of September, there had been 328 injuries requiring hospital treatment, 8 fatalities, and 113 arrests (1). At least 500 houses had been damaged beyond repair and 4,000 people rendered homeless. Some 200 streets were heavily barricaded and guarded, while much of the city was effectively under military occupation.

Drugs: personality:: personality: drugs

The concepts, drug and personality, are conceptually similar, fulfill similar functions, and are defined by similar operations in their respective domains. Usual studies of drug-personality interaction imply mind-body dualism. A monistic concept is set forth and some implications of extending methods from personality psychology to pharmacology and from pharmacology to personality psychology are set forth.