Clinical and Genetic Factors Associated with Resistance to Treatment in Patients with Schizophrenia: A Case-Control Study

Predicting treatment resistance in schizophrenia patients: Machine learning highlights the role of early pathophysiologic features

Detecting patients with a high-risk profile for treatment-resistant schizophrenia (TRS) can be beneficial for implementing individually adapted therapeutic strategies and better understanding the TRS etiology. The aim of this study was to explore, with machine learning methods, the impact of demographic and clinical patient characteristics on TRS prediction, for already established risk factors and unexplored ones. This was a retrospective study of 500 patients admitted during 2020 to the University Hospital Group for Paris Psychiatry. We hypothesized potential TRS risk factors. The selected features were coded into structured variables in a new dataset, by processing patients discharge summaries and medical narratives with natural-language processing methods. We compared three machine learning models (XGBoost, logistic elastic net regression, logistic regression without regularization) for predicting TRS outcome. We analysed feature impact on the models, suggesting the following factors as markers of a high-risk TRS profile: early age at first contact with psychiatry, antipsychotic treatment interruptions due to non-adherence, absence of positive symptoms at baseline, educational problems and adolescence mental disorders in the personal psychiatric history. Specifically, we found a significant association with TRS outcome for age at first contact with psychiatry and medication non-adherence. Our findings on TRS risk factors are consistent with the review of the literature and suggest potential in using early pathophysiologic features for TRS prediction. Results were encouraging with the use of natural-langage processing techniques to leverage raw data provided by discharge summaries, combined with machine leaning models. These findings are a promising step for helping clinicians adapt their guidelines to early detection of TRS.

Pharmacogenomics in Lebanon: current status, challenges and opportunities

Pharmacogenomics (PGx) research and applications are of utmost relevance in Lebanon considering its population genetic diversity. Moreover, as a country with regional leadership in medicine and higher education, Lebanon holds a strong potential in contributing to PGx research and clinical implementation. In this manuscript, we first review and evaluate the available PGx research conducted in Lebanon, then describe the current status of PGx practice in Lebanon while reflecting on the local and regional challenges, and highlighting areas for action, and opportunities to move forward. We specifically expand on the status of PGx at the American University of Beirut Faculty of Medicine and Medical Center as a case study and guide for the further development of local and regional comprehensive PGx research, teaching, and clinical implementation programs. We also delve into the status of PGx knowledge and education, and prospects for further advancement such as with online courses and certificates.

Association of DRD2, DRD4 and COMT genes variants and their gene-gene interactions with antipsychotic treatment response in patients with schizophrenia

Antipsychotic drugs are the first line of treatment in schizophrenia; although antipsychotic responses indicate a wide interindividual variety in patients with schizophrenia. This study aimed to investigate the association between four polymorphisms in DRD2, DRD4 and COMT genes and their gene-gene interactions with antipsychotic treatment response in patients with schizophrenia. A total of 101 patients with schizophrenia were recruited and stratified in treatment responder and treatment resistant groups based on the published criteria of resistant to treatment using PANSS. Clinical and demographic factors were analyzed. Genomic DNA was extracted from whole blood and genotyping for the four polymorphisms were done by ARMS-PCR, PCR-RFLP and gap-PCR. Gene-gene interactions were analyzed by logistic regression. In case of DRD2 A-241G, G allele was significantly associated with resistant to treatment. Regarding DRD4 120-bp duplication, 240/240 genotype was significantly associated with resistant to treatment comparing to other genotypes in a dominant model. The genotype combination of DRD4 240/240 and COMT Val/Val was significantly associated with treatment resistant. Among DRD2 AA genotype, COMT met allele carriers which also had a 120 bp allele of DRD4 had a significantly better response to antipsychotics. Moreover, analysis of clinical and demographic factors demonstrated a significantly longer duration of hospitalization and higher chlorpromazine-equivalent daily dose in resistant to treatment patients. Discovering the polymorphisms which effect treatment response to antipsychotics will provide the possibility of genetic screening before starting an antipsychotic treatment which enhances the chance of responding to antipsychotics and decreases drugs side effects and costs.

Treatment-Resistant Schizophrenia, Clozapine Resistance, Genetic Associations, and Implications for Precision Psychiatry: A Scoping Review

Treatment-resistant schizophrenia (TRS) is often associated with severe burden of disease, poor quality of life and functional impairment. Clozapine is the gold standard for the treatment of TRS, although it is also known to cause significant side effects in some patients. In view of the burgeoning interest in the role of genetic factors in precision psychiatry, we conducted a scoping review to narratively summarize the current genetic factors associated with TRS, clozapine resistance and side effects to clozapine treatment. We searched PubMed from inception to December 2022 and included 104 relevant studies in this review. Extant evidence comprised associations between TRS and clozapine resistance with genetic factors related to mainly dopaminergic and serotoninergic neurotransmitter systems, specifically, TRS and rs4680, rs4818 within COMT, and rs1799978 within DRD2; clozapine resistance and DRD3 polymorphisms, CYP1A2 polymorphisms; weight gain with LEP and SNAP-25 genes; and agranulocytosis risk with HLA-related polymorphisms. Future studies, including replication in larger multi-site samples, are still needed to elucidate putative risk genes and the interactions between different genes and their correlations with relevant clinical factors such as psychopathology, psychosocial functioning, cognition and progressive changes with treatment over time in TRS and clozapine resistance.

Exploring the trend of Schizophrenia at Hiwot Fana specialized university referral hospital, Eastern, Ethiopia (2016-2020): A 5-year retrospective analysis

Schizophrenia is one of the most troublesome psychiatric problems requiring long-term antipsychotic treatments. There is a scarcity of data regarding its overtime trend in Ethiopia.

Profiles and factors associated with schizophrenia in eastern Ethiopia: A matched case-control study

Background

Despite its strong hereditary and genetic connections, there are other factors reported to be linked to schizophrenia, but not well studied in eastern Ethiopia.

Objective

This study was aimed to investigating the potential profiles and factors associated with schizophrenia in eastern Ethiopia.

Materials and methods

A matched case-control study was conducted in two public hospitals from December 1, 2021, to January 30, 2022. Cases were patients with schizophrenia who visited the hospitals, and controls were healthy individuals without any mental illness who visited the same hospitals. A questionnaire was used to collect the data. Cases and controls were matched using age and sex. STATA-14 was used for analysis. A conditional logistic regression with an adjusted odds ratio (AOR) and a 95% confidence interval (CI) was applied to identify the determinants. P-values of <0.05 were used to build the final model as a measure of statistical significance.

Results

The mean age of the study participants group was 28.6 (±8.44) years, mean age for cases was 28.7(±8.5) ranging from 18 to 56 years and the mean age for the controls was 28.4 (±8.5), ranging from 18 to 60 years. About 181 (83.03%) of the participants were male. The odds of having schizophrenia was about 12.2 times higher among participants with family history of mental illness (AOR: 12.21; 95% CI: 4.83-30.00). The odds of having schizophrenia was 4.5 times higher among polysubstance users (AOR: 4.45; 95% CI: 1.28-5.45) and 2.8 times higher among khat consumers (AOR: 2.82; 95% CI: 1.23-6.45) compared to their counterparts.

Conclusion

Our findings show that genetic risk factors as well as some modifiable behaviors are associated to schizophrenia in eastern Ethiopia. At all levels, special attention should be given to those who are at risk.

Peripheral biomarkers of treatment-resistant schizophrenia: Genetic, inflammation and stress perspectives

Treatment-resistant schizophrenia (TRS) often results in severe disability and functional impairment. Currently, the diagnosis of TRS is largely exclusionary and emphasizes the improvement of symptoms that may not be detected early and treated according to TRS guideline. As the gold standard, clozapine is the most prescribed selection for TRS. Therefore, how to predict TRS in advance is critical for forming subsequent treatment strategy especially clozapine is used during the early stage of TRS. Although mounting studies have identified certain clinical factors and neuroimaging characteristics associated with treatment response in schizophrenia, the predictors for TRS remain to be explored. Biomarkers, particularly for peripheral biomarkers, show great potential in predicting TRS in view of their predictive validity, noninvasiveness, ease of testing and low cost that would enable their widespread use. Recent evidence supports that the pathogenesis of TRS may be involved in abnormal neurotransmitter systems, inflammation and stress. Due to the heterogeneity of TRS and the lack of consensus in diagnostic criteria, it is difficult to compare extensive results among different studies. Based on the reported neurobiological mechanisms that may be associated with TRS, this paper narratively reviews the updates of peripheral biomarkers of TRS, from genetic and other related perspectives. Although current evidence regarding biomarkers in TRS remains fragmentary, when taken together, it can help to better understand the neurobiological interface of clinical phenotypes and psychiatric symptoms, which will enable individualized prediction and therapy for TRS in the long run.

The effect of medication adherence on psychosocial adjustment to body weight, image, and self-esteem in patients with schizophrenia

PURPOSE

The present study aimed to evaluate the effect of medication adherence on psychosocial adjustment to body weight, image, and self-esteem in patients with schizophrenia.

DESIGN AND METHODS

This cross-sectional and correlational study consisted of 154 patients with schizophrenia registered in a Community Mental Health Center.

FINDINGS

The patients had moderate psychosocial adjustment to body weight, image, and self-esteem, and 56.5% had poor medication adherence. There was a significant positive correlation between participants' medication adherence and psychosocial adjustment to body weight, image, and self-esteem.

PRACTICE IMPLICATIONS

Psychiatric nurses should support patients regarding medication adherence, and psychosocial adjustment to body weight, image, and self-esteem.

Impact of spirituality and religiosity on suicidal risk among a sample of lebanese psychiatric in-patients

OBJECTIVES

To evaluate the prevalence of suicidality among the psychiatric inpatients community in Lebanon, and to elucidate the effect of religiosity and spirituality on suicidal thoughts or behaviours.

METHODS

A total sample of 159 patient consecutively admitted to a psychiatric hospital was interviewed. The Ask Suicide-screening Questionnaire (ASQ) was used to assess suicidal risk; the Mature Religiosity Scale (MRS) and the Spirituality Index for Well Being (SIWB) scales were used to assess religiosity and spirituality.

RESULTS

We found that 45.6% of the participants screened positively on the ASQ, including 37.5% with acute suicidal ideation. A backward logistic regression, taking the negative/positive screening ASQ as the dependent variable, showed that a positive family history of suicide and depression were significantly associated with higher positive suicidal screening, whereas higher spirituality was significantly associated with lower positive suicidal screening. When forcing the mature religiosity scale as an independent variable, the results remained the same.

CONCLUSION

Spiritual well-being might be considered an important factor to explore among psychiatric patients. Psychiatric inpatients have a high risk for suicide; the challenge remains for clinicians to identify upon admission patients that are most likely to die from suicide.Key pointsA positive family history of suicide and depression was significantly associated with higher suicidality.Higher spirituality, but not religiosity, was significantly associated with lower suicidality.Spiritual well-being might be considered an important factor to explore among psychiatric patients.The challenge remains for clinicians to identify patients that are most likely to die from suicide upon admission.

Interacting Roles of COMT and GAD1 Genes in Patients with Treatment-Resistant Schizophrenia: a Genetic Association Study of Schizophrenia Patients and Healthy Controls

The projection from dopaminergic neurons to gamma-aminobutyric acid (GABA) interneurons in the prefrontal cortex is involved in the etiology of schizophrenia. The impact of interacting effects between dopamine signals and the expression of GABA on the clinical phenotypes of schizophrenia has not been studied. Since these interactions could be closely involved in prefrontal cortex functions, patients with specific alleles of these relevant molecules (which lead to lower or vulnerable genetic functions) may develop treatment-refractory symptoms. We conducted a genetic association study focusing on COMT and GAD1 genes for a treatment-resistant schizophrenia (TRS) group (n=171), a non-TRS group (n=592), and healthy controls (HC: n=447), and we examined allelic combinations specific to TRS. The results revealed that the percentage of subjects with Met allele of rs4680 on the COMT gene and C/C homozygote of rs3470934 on the GAD1 gene was significantly higher in the TRS group than the other two groups. There was no significant difference between the non-TRS group and HC groups. Considering the direction of functions of these single-nucleotide polymorphisms revealed by previous studies, we speculate that subjects with the Met/CC allelic combination could have a higher dopamine level and a lower expression of GABA in the prefrontal cortex. Our results suggest that an interaction between the dopaminergic signal and GABA signal intensities could differ between TRS patients and patients with other types of schizophrenia and healthy subjects.

Negative symptoms in schizophrenia: correlation with clinical and genetic factors

Aim: Explore the possible association between clinical factors and genetic variants of the dopamine pathways and negative symptoms. Materials & methods: Negative symptoms were assessed in 206 patients with schizophrenia using the Arabic version of the self-evaluation of negative symptoms scale and the Positive and Negative Syndrome Scale. Genotyping for COMT, DRD2, MTHFR and OPRM1 genes was performed. Results: Multivariable analysis showed that higher self-evaluation of negative symptoms scale scores were significantly associated with higher age, higher chlorpromazine-equivalent daily dose for typical antipsychotics and in married patients. Higher negative Positive and Negative Syndrome Scale scores were significantly associated with women and having the CT genotype for MTHFR c.677C>T (β = 4.25; p = 0.008) compared with CC patients. Conclusion: Understanding both clinical/genetic factors could help improve the treatment of patients.

Validation of the Arabic version of the "self-evaluation of negative symptoms" scale (SNS)

BACKGROUND

The self-evaluation of negative symptoms scale (SNS) is a new easy-to-use self-administered questionnaire allowing clinicians to understand the clinical and genetic factors affecting the negative symptoms in patients with schizophrenia. There was a need to translate and validate this scale in Arabic so that Arab-speaking patients benefit from it. Therefore, the aim of our study was to validate the Arabic version of the SNS in a sample of Lebanese patients with schizophrenia.

METHODS

The Arabic SNS was used to quantify the disability associated with negative symptoms in patients with schizophrenia (n = 206). Six weeks after completing the SNS, the participants were interviewed again to assess test-retest reproducibility. The validity was confirmed by factor analyses using the principal component analysis technique with a varimax rotation. The Positive and Negative Syndrome Scale (PANSS) was also assessed.

RESULTS

None of the items of the SNS scale were removed; all items converged over a solution of five factors that had an eigenvalue > 1, explaining a total of 66.01% of the variance (Cronbach's alpha = 0.879; test part). The mean total SNS score was 17.33 ± 8.43 for the "test", and 16.35 ± 7.50 for the "retest". The correlation coefficients between the SNS total score and the PANSS scale and subscales were as follows: total PANSS (r = 0.044; p = 0.530), positive PANSS score (r = - 0.106; p = 0.131), negative PANSS score (r = 0.204; p = 0.003), and general psychopathological PANSS score (r = 0.03; p = 0.530).

CONCLUSION

This study is the first to validate the Arabic version of the SNS in patients with schizophrenia. Using this scale would help improve treatment by correctly assessing negative symptoms, thus optimizing treatment options.

Indicated association between polygenic risk score and treatment-resistance in a naturalistic sample of patients with schizophrenia spectrum disorders

BACKGROUND

One third of people diagnosed with schizophrenia fail to respond adequately to antipsychotic medication, resulting in persisting disabling symptoms, higher rates of hospitalization and higher costs for society. In an effort to better understand the mechanisms behind resistance to antipsychotic treatment in schizophrenia, we investigated its potential relationship to the genetic architecture of the disorder.

METHODS

Patients diagnosed with a schizophrenia spectrum disorder (N = 321) were classified as either being treatment-resistant (N = 108) or non-treatment-resistant (N = 213) to antipsychotic medication using defined consensus criteria. A schizophrenia polygenic risk score based on genome-wide association studies (GWAS) was calculated for each patient and binary logistic regression was performed to investigate the association between polygenetic risk and treatment resistance. We adjusted for principal components, batch number, age and sex. Additional analyses were performed to investigate associations with demographic and clinical variables.

RESULTS

High levels of polygenic risk score for schizophrenia significantly predicted treatment resistance (p = 0.003). The positive predictive value of the model was 61.5% and the negative predictive value was 71.7%. The association was significant for one (p = 0.01) out of five tested SNP significance thresholds. Season of birth was able to predict treatment-resistance in the regression model (p = 0.05).

CONCLUSIONS

The study indicates that treatment-resistance to antipsychotic medication is associated with higher polygenetic risk of schizophrenia, suggesting a link between antipsychotics mechanism of action and the genetic underpinnings of the disorder.