Association of duration of treatment on post-discharge mortality in forensic psychiatric patients in Finland.

Background: Longer treatment time has been shown to be associated with lower crime recidivism among forensic psychiatric patients, but it is not known if this applies also to mortality. In this study, we aim to research whether treatment time is associated with risk of post-discharge mortality in Finnish forensic psychiatric patients. Materials and methods: The study population consisted of 989 patients committed to compulsory forensic psychiatric hospital treatment in Finland from 1980 to 2009 who were released from care by the end of 2018. Each patient included in the cohort was linked with the Statistics Finland register, which includes all data on dates and causes of deaths in Finland. Crude cumulative rate of mortality were estimated using Kaplan-Meier method and compared using logrank-test. Adjusted cumulative rate analyzed using Cox regression model. A possible nonlinear relationship between the treatment time and the hazard of death was assessed by using 3-knot-restricted cubic spline regression. Adjusted models included age, sex, and SUD (substance use disorder) as covariates. Results: The mean duration of care was 7.1 (SD 6) years. The duration of treatment variable was divided into tertiles of treatment duration less than 3.5 years, 3.5-7.9 years and equal or more than 8 years. The risk of mortality was highest in the first tertile, and lowest in the last tertile. The risk of mortality was higher for patients suffering from SUD, for patients of male sex and for those released at younger age. Conclusions: Longer treatment time is associated with reduced post-discharge mortality in forensic psychiatric patients in Finland. Especially males and individuals with SUD are at higher mortality risk after release, but longer treatment duration may mitigate these risks. Longer periods of hospitalization have to be, however, viewed against the backdrop of institutionalization and loss of self-determination.

Astrocytes Regulate Neuronal Network Burst Frequency Through NMDA Receptors in a Species- and Donor-Specific Manner.

Background: Development of synaptic activity is a key neuronal characteristic that relies largely on interactions between neurons and astrocytes. Although astrocytes have known roles in regulating synaptic function and malfunction, the use of human- or donor-specific astrocytes in disease models is still rare. Rodent astrocytes are routinely used to enhance neuronal activity in cell cultures, but less is known about how human astrocytes influence neuronal activity. Methods: We established human induced pluripotent stem cell-derived neuron-astrocyte cocultures and studied their functional development on microelectrode array. We used cell lines from 5 neurotypical control individuals and 3 pairs of monozygotic twins discordant for schizophrenia. A method combining NGN2 overexpression and dual SMAD inhibition was used for neuronal differentiation. The neurons were cocultured with human induced pluripotent stem cell-derived astrocytes differentiated from 6-month-old astrospheres or rat astrocytes. Results: We found that the human induced pluripotent stem cell-derived cocultures developed complex network bursting activity similar to neuronal cocultures with rat astrocytes. However, the effect of NMDA receptors on neuronal network burst frequency (NBF) differed between cocultures containing human or rat astrocytes. By using cocultures derived from patients with schizophrenia and unaffected individuals, we found lowered NBF in the affected cells. We continued by demonstrating how astrocytes from an unaffected individual rescued the lowered NBF in the affected neurons by increasing NMDA receptor activity. Conclusions: Our results indicate that astrocytes participate in the regulation of neuronal NBF through a mechanism that involves NMDA receptors. These findings shed light on the importance of using human and donor-specific astrocytes in disease modeling.

Nerve cell connections called synapses are formed in interaction with astrocytes, the main non-neuronal cell type of the brain. In vitro work commonly uses rodent astrocytes to enhance activity in human-derived neuronal cell cultures, but differences in using rodent versus human astrocytes are not well understood. We found that the electrical activity of nerve cell networks in cultures consisting of human cortical nerve cells and human astrocytes is altered when the astrocytes are from patients with schizophrenia, relative to neurotypical individuals. The effect of human astrocytes on these networks differed from rodent astrocytes, indicating the potential importance of a fully human culture system.

Integrative metabolomics-genomics analysis identifies key networks in a stem cell-based model of schizophrenia.

Schizophrenia (SCZ) is a neuropsychiatric disorder, caused by a combination of genetic and environmental factors. The etiology behind the disorder remains elusive although it is hypothesized to be associated with the aberrant response to neurotransmitters, such as dopamine and glutamate. Therefore, investigating the link between dysregulated metabolites and distorted neurodevelopment holds promise to offer valuable insights into the underlying mechanism of this complex disorder. In this study, we aimed to explore a presumed correlation between the transcriptome and the metabolome in a SCZ model based on patient-derived induced pluripotent stem cells (iPSCs). For this, iPSCs were differentiated towards cortical neurons and samples were collected longitudinally at various developmental stages, reflecting neuroepithelial-like cells, radial glia, young and mature neurons. The samples were analyzed by both RNA-sequencing and targeted metabolomics and the two modalities were used to construct integrative networks in silico. This multi-omics analysis revealed significant perturbations in the polyamine and gamma-aminobutyric acid (GABA) biosynthetic pathways during rosette maturation in SCZ lines. We particularly observed the downregulation of the glutamate decarboxylase encoding genes GAD1 and GAD2, as well as their protein product GAD65/67 and their biochemical product GABA in SCZ samples. Inhibition of ornithine decarboxylase resulted in further decrease of GABA levels suggesting a compensatory activation of the ornithine/putrescine pathway as an alternative route for GABA production. These findings indicate an imbalance of cortical excitatory/inhibitory dynamics occurring during early neurodevelopmental stages in SCZ. Our study supports the hypothesis of disruption of inhibitory circuits to be causative for SCZ and establishes a novel in silico approach that enables for integrative correlation of metabolic and transcriptomic data of psychiatric disease models.

Genetic contribution to microglial activation in schizophrenia.

Several lines of evidence indicate the involvement of neuroinflammatory processes in the pathophysiology of schizophrenia (SCZ). Microglia are brain resident immune cells responding toward invading pathogens and injury-related products, and additionally, have a critical role in improving neurogenesis and synaptic functions. Aberrant activation of microglia in SCZ is one of the leading hypotheses for disease pathogenesis, but due to the lack of proper human cell models, the role of microglia in SCZ is not well studied. We used monozygotic twins discordant for SCZ and healthy individuals to generate human induced pluripotent stem cell-derived microglia to assess the transcriptional and functional differences in microglia between healthy controls, affected twins and unaffected twins. The microglia from affected twins had increased expression of several common inflammation-related genes compared to healthy individuals. Microglia from affected twins had also reduced response to interleukin 1 beta (IL1ß) treatment, but no significant differences in migration or phagocytotic activity. Ingenuity Pathway Analysis (IPA) showed abnormalities related to extracellular matrix signaling. RNA sequencing predicted downregulation of extracellular matrix structure constituent Gene Ontology (GO) terms and hepatic fibrosis pathway activation that were shared by microglia of both affected and unaffected twins, but the upregulation of major histocompatibility complex (MHC) class II receptors was observed only in affected twin microglia. Also, the microglia of affected twins had heterogeneous response to clozapine, minocycline, and sulforaphane treatments. Overall, despite the increased expression of inflammatory genes, we observed no clear functional signs of hyperactivation in microglia from patients with SCZ. We conclude that microglia of the patients with SCZ have gene expression aberrations related to inflammation response and extracellular matrix without contributing to increased microglial activation.

General and violent recidivism of former forensic psychiatric patients in Finland.

Background: Forensic psychiatric care in Finland is provided to individuals who have committed a crime due to a serious mental disorder and are in need of psychiatric care. The reconviction (recidivism) rates for this patient group vary in time and between countries, likely due to different treatment practices and requirements for forensic care. Materials and methods: We set out to study criminal recidivism in a national cohort of all patients released from forensic psychiatric care in Finland between 1999 and 2018. National registries were used to identify the patients and gain information on their criminal sentences. Forensic psychiatric examinations were used to record demographic information for the cohort. The cohort was followed up from hospital discharge to the end of 2019. Results: We identified a total of 501 patients who were released from forensic psychiatric care (mean age: 46.6 years [SD 13.4), 434 (86.6%) were male). The mean and median times spent in treatment for the cohort was 10.0 years [SD 6.5] and 8.7 years, respectively. 91% of the patients had schizophrenia spectrum disorder (F2*), and 63.5% had a substance use disorder. A total of 83 patients (16.6%) committed any crime after being released from care, and the mean time to recidivism was 3.8 years. The recidivism rate was 2015 per 100,000 person years. A total of 48 patients (9.6%) committed a violent crime. The mean time to violent recidivism was 4.2 years. The violent recidivism rate was 1,083 per 100,000 person years. A longer duration of treatment was associated with a decreased risk of general recidivism (HR 0.95, 95% CI 0.90 to 1.00, p = 0.05). Factors associated with higher recidivism were male sex, having a comorbid substance use disorder and younger age at discharge. Conclusion: The recidivism rate in Finland was markedly lower than has been previously reported for other Western countries, and the mean duration of treatment was also longer. A longer treatment time may reduce the risk of criminal recidivism in forensic psychiatric patients. The results suggest, as previous studies have found, that more effort is indicated on the treatment of substance abuse.

Contribution of astrocytes to familial risk and clinical manifestation of schizophrenia.

Previous studies have implicated several brain cell types in schizophrenia (SCZ), but the genetic impact of astrocytes is unknown. Considering their high complexity in humans, astrocytes are likely key determinants of neurodevelopmental diseases, such as SCZ. Human induced pluripotent stem cell (hiPSC)-derived astrocytes differentiated from five monozygotic twin pairs discordant for SCZ and five healthy subjects were studied for alterations related to high genetic risk and clinical manifestation of SCZ in astrocyte transcriptomics, neuron-astrocyte co-cultures, and in humanized mice. We found gene expression and signaling pathway alterations related to synaptic dysfunction, inflammation, and extracellular matrix components in SCZ astrocytes, and demyelination in SCZ astrocyte transplanted mice. While Ingenuity Pathway Analysis identified SCZ disease and synaptic transmission pathway changes in SCZ astrocytes, the most consistent findings were related to collagen and cell adhesion associated pathways. Neuronal responses to glutamate and GABA differed between astrocytes from control persons, affected twins, and their unaffected co-twins and were normalized by clozapine treatment. SCZ astrocyte cell transplantation to the mouse forebrain caused gene expression changes in synaptic dysfunction and inflammation pathways of mouse brain cells and resulted in behavioral changes in cognitive and olfactory functions. Differentially expressed transcriptomes and signaling pathways related to synaptic functions, inflammation, and especially collagen and glycoprotein 6 pathways indicate abnormal extracellular matrix composition in the brain as one of the key characteristics in the etiology of SCZ.

Psychosis and the Risk of Stranger Homicides.

Introduction: Psychosis increases the risk of committing homicide, but it remains unclear whether it also affects victim selection. Individual cases of stranger homicide elicit a lot of public attention and outrage, even though evidence of their incidence is scarce. Methods: Forensic psychiatric reports of 389 patients who had committed homicide in Finland during 1980-2014 were examined to determine the relationship between the offender and the victim. The stranger homicide incidence derived from perpetrators with psychosis was compared to a comparative incidence derived from a group of perpetrators without psychosis (other mental disorders were not excluded) over the time frame 2003-2014. Stranger homicide incidence rates were calculated using Finnish population averages of the study years, assuming a Poisson distribution and reported as per 100 000 person-years among potential victims in the Finnish general population. Results: Three hundred and eighty nine patients with psychosis had committed 414 homicides, with 40 complete stranger victims and 15 victims known for less than 24 h. Complete stranger homicide incidence committed by individuals with psychosis was 0.022 per 100 000 person-years and 0.13 for individuals without psychosis. When also including victims known for < 24 h, the incidence was 0.031 for individuals with psychosis and 0.28 for individuals without psychosis per 100 000 person-years. Discussion: Nine out of ten stranger homicides are committed by individuals without psychosis. However, on the basis of a 3.1% prevalence of psychotic disorders in Finland, individuals with psychosis have about a 3- to 5-fold risk of committing stranger homicides as compared to individuals without psychosis.

Molecular signaling pathways underlying schizophrenia.

The molecular pathophysiological mechanisms underlying schizophrenia have remained unknown, and no treatment exists for primary prevention. We used Ingenuity Pathway Analysis to analyze canonical and causal pathways in two different datasets, including patients from Finland and USA. The most significant findings in canonical pathway analysis were observed for glutamate receptor signaling, hepatic fibrosis, and glycoprotein 6 (GP6) pathways in the Finnish dataset, and GP6 and hepatic fibrosis pathways in the US dataset. In data-driven causal pathways, ADCYAP1, ADAMTS, and CACNA genes were involved in the majority of the top 10 pathways differentiating patients and controls in both Finnish and US datasets. Results from a Finnish nation-wide database showed that the risk of schizophrenia relapse was 41% lower among first-episode patients during the use of losartan, the master regulator of an ADCYAP1, ADAMTS, and CACNA-related pathway, compared to those time periods when the same individual did not use the drug. The results from the two independent datasets suggest that the GP6 signaling pathway, and the ADCYAP1, ADAMTS, and CACNA-related purine, oxidative stress, and glutamatergic signaling pathways are among primary pathophysiological alterations in schizophrenia among patients with European ancestry. While no reproducible dopaminergic alterations were observed, the results imply that agents such as losartan, and ADCYAP1/PACAP -deficit alleviators, such as metabotropic glutamate 2/3 agonist MGS0028 and 5-HT7 antagonists - which have shown beneficial effects in an experimental Adcyap1-/- mouse model for schizophrenia - could be potential treatments even before the full manifestation of illness involving dopaminergic abnormalities.

Neurobiological roots of psychopathy.

Psychopathy is an extreme form of antisocial behavior, with about 1% prevalence in the general population, and 10-30% among incarcerated criminal offenders. Although the heritability of severe antisocial behavior is up to 50%, the genetic background is unclear. The underlying molecular mechanisms have remained unknown but several previous studies suggest that abnormal glucose metabolism and opioidergic neurotransmission contribute to violent offending and psychopathy. Here we show using iPSC-derived cortical neurons and astrocytes from six incarcerated extremely antisocial and violent offenders, three nonpsychopathic individuals with substance abuse, and six healthy controls that there are robust alterations in the expression of several genes and immune response-related molecular pathways which were specific for psychopathy. In neurons, psychopathy was associated with marked upregulation of RPL10P9 and ZNF132, and downregulation of CDH5 and OPRD1. In astrocytes, RPL10P9 and MT-RNR2 were upregulated. Expression of aforementioned genes explained 30-92% of the variance of psychopathic symptoms. The gene expression findings were confirmed with qPCR. These genes may be relevant to the lack of empathy and emotional callousness seen in psychopathy, since several studies have linked these genes to autism and social interaction.

Correction: Neurobiological roots of psychopathy.

A correction to this paper has been published and can be accessed via a link at the top of the paper.

Substance Abuse and Excessive Mortality Among Forensic Psychiatric Patients: A Finnish Nationwide Cohort Study.

Background: Forensic psychiatric patients are known to have reduced life expectancy. The aim of this study was to explore to what extent substance abuse disorders account for this increased mortality. Methods: Data up to December 31, 2016 for mortality (causes of death register) and substance abuse (forensic psychiatric examinations) were collected for all of the 950 patients committed to involuntary forensic psychiatric hospital care in Finland during 1980-2009 and discharged no later than December 31, 2016. Patients were then classified as suffering or not suffering from substance abuse disorders and their causes of death were examined. The standardized mortality ratio was then calculated for these groups on the basis of sex-, age-, and calendar-period-specific mortality rates for the general Finnish population. Results: During the follow-up time (mean 13.4 years), 354 (320 men, 34 women) patients died, resulting in a standardized mortality ratio of 3.5. The standardized mortality ratio for the patients with a history of substance abuse disorders was 4.1 compared to 2.8 for those with no such history. Among men, but not women, the age-adjusted proportion of death was significantly higher for those with a history of substance abuse disorders. In addition, in patients with a history of substance abuse disorders, the male age-adjusted competing risk of mortality was higher for unnatural causes, but not natural causes. Furthermore, a prominent proportion (16%) of all deaths and a majority of the accidental deaths (64%) occurred under the influence of some substance. Conclusions: Substance abuse is a major factor causing excessive mortality among forensic psychiatric patients. The management of substance abuse problems should be one cornerstone of the treatment of patients with both severe mental disorders and substance abuse disorders during their time in hospital and this should be extended to outpatient care.

Sex-specific transcriptional and proteomic signatures in schizophrenia.

It has remained unclear why schizophrenia typically manifests after adolescence and which neurobiological mechanisms are underlying the cascade leading to the actual onset of the illness. Here we show that the use of induced pluripotent stem cell-derived neurons of monozygotic twins from pairs discordant for schizophrenia enhances disease-specific signal by minimizing genetic heterogeneity. In proteomic and pathway analyses, clinical illness is associated especially with altered glycosaminoglycan, GABAergic synapse, sialylation, and purine metabolism pathways. Although only 12% of all 19,462 genes are expressed differentially between healthy males and females, up to 61% of the illness-related genes are sex specific. These results on sex-specific genes are replicated in another dataset. This implies that the pathophysiology differs between males and females, and may explain why symptoms appear after adolescence when the expression of many sex-specific genes change, and suggests the need for sex-specific treatments.

Cause-specific mortality in Finnish forensic psychiatric patients.

PURPOSE: To analyze the causes of mortality among patients committed to compulsory forensic psychiatric hospital treatment in Finland during 1980-2009 by categorizing the causes of mortality into somatic diseases, suicides and other unnatural deaths. MATERIALS AND METHODS: The causes of mortality were analyzed among 351 patients who died during the follow-up. Standardized mortality ratio (SMR) was calculated as the ratio of observed and expected number of deaths by using the subject-years methods with 95% confidence intervals, assuming a Poisson distribution. The expected number of deaths was calculated on the basis of sex-, age- and calendar-period-specific mortality rates for the Finnish population. RESULTS: The vast majority (249/351) of deaths were due to a somatic disease with SMR of 2.6 (mean age at death 61 years). Fifty nine patients committed suicide with a SMR of 7.1 (mean age at death 40 years). Four patients were homicide victims (mean age at death 40 years) and 32 deaths were accidental (mean age at death 52 years). The combined homicides and accidental deaths resulted in a SMR of 1.7. CONCLUSIONS: The results of this study point out that the high risk for suicide should receive attention when the hospital treatment and the outpatient care is being organized for forensic psychiatric patients. In addition, the risk of accidents should be evaluated and it should be assured that the patients receive proper somatic healthcare during the forensic psychiatric treatment and that it continues also in the outpatient setting.

Mortality among forensic psychiatric patients in Finland.

BACKGROUND: Both mental illness and criminality are associated with higher risk of early death, yet the mortality among forensic psychiatric patients who are affected by both mental illness and criminal behaviour has scarcely been studied. AIMS: To analyse the mortality among all patients who were committed to a compulsory forensic psychiatric hospital treatment in Finland between 1980 and 2009. Mortality was analysed according to the age when the patient was committed to forensic treatment. RESULTS: A total of 1253 patients were included, of which 153 were females and 1100 were males. The mean follow-up time in this study was 15.1 years, and 351 (28%) had died during the follow-up period. The standardized mortality rate (SMR) for the whole study group was 2.97 (95% CI 2.67-3.29). Among females the SMR was 3.62 (95% CI 2.57-5.09), and among males 2.91 (95% CI 2.61-3.25). The SMRs were higher when patients were committed to forensic treatment before the age of 40 years. CONCLUSION: This study showed an increased mortality among forensic psychiatric patients compared with the general population and the mortality was inversely proportional to the age when the treatment had begun. In contrast to the earlier studies, the mortality in this study was lower indicating that prolonged treatment may have an overall protective effect on forensic psychiatric patients.

Psychopathy, PCL-R, and MAOA genotype as predictors of violent reconvictions.

The Revised Psychopathy Checklist (PCL-R) has shown a moderate association with violence. The efficacy of PCL-R in varying monoamine oxidase A (MAOA) genotypes is, however, unexamined. The aim of this study was to investigate the effect of PCL-R and psychopathy on the risk for violent reconvictions among 167 MAOA genotyped alcoholic offenders. Violent reconvictions and PCL-R scores among violent offenders were assessed after a 7-year non-incarcerated follow-up. Regression analysis was used to evaluate the alcohol exposure and age-adjusted effect of PCL-R score and psychopathy on the risk for reconvictions among differing MAOA genotypes. Results suggest that the PCL-R total score predicts impulsive reconvictions among high-activity MAOA offenders (6.8% risk increase for every one-point increase in PCL-R total score, P = 0.015), but not among low-activity MAOA offenders, whereas antisocial behavior and attitudes predicted reconvictions in both genotypes (17% risk increase among high-activity MAOA offenders and 12.8% increase among low-activity MAOA offenders for every one-point increase in factor 2 score). Both narcissistic self-image with related interpersonal style (factor 1 score) and psychopathy (PCL-R ≥ 30) failed to predict future violence. Results suggest that the efficacy of PCL-R is altered by MAOA genotype, alcohol exposure, and age, which seems important to note when PCL-R is used for risk assessments that will have legal or costly preventive work consequences.