Evidence for effective interventions to reduce mental health-related stigma and discrimination in the medium and long term: systematic review.

BACKGROUND: Most research on interventions to counter stigma and discrimination has focused on short-term outcomes and has been conducted in high-income settings. AIMS: To synthesise what is known globally about effective interventions to reduce mental illness-based stigma and discrimination, in relation first to effectiveness in the medium and long term (minimum 4 weeks), and second to interventions in low- and middle-income countries (LMICs). METHOD: We searched six databases from 1980 to 2013 and conducted a multi-language Google search for quantitative studies addressing the research questions. Effect sizes were calculated from eligible studies where possible, and narrative syntheses conducted. Subgroup analysis compared interventions with and without social contact. RESULTS: Eighty studies (n = 422 653) were included in the review. For studies with medium or long-term follow-up (72, of which 21 had calculable effect sizes) median standardised mean differences were 0.54 for knowledge and -0.26 for stigmatising attitudes. Those containing social contact (direct or indirect) were not more effective than those without. The 11 LMIC studies were all from middle-income countries. Effect sizes were rarely calculable for behavioural outcomes or in LMIC studies. CONCLUSIONS: There is modest evidence for the effectiveness of anti-stigma interventions beyond 4 weeks follow-up in terms of increasing knowledge and reducing stigmatising attitudes. Evidence does not support the view that social contact is the more effective type of intervention for improving attitudes in the medium to long term. Methodologically strong research is needed on which to base decisions on investment in stigma-reducing interventions.

Strategies to deal with comorbid physical illness in psychosis.

Individuals with serious mental illnesses such as psychosis still experience higher mortality rates than the general population, decades after data have linked the gap to increased rates of physical illness, delayed diagnosis, low treatment rates and worse outcomes from treatment received. The nature of the relationship between psychosis and comorbid physical illness is complex. Multiple strategies directed at different levels of disease process, health care systems and stakeholder culture are likely required to make sustained progress in reducing the mortality gap. Evidence for strategies that effectively reduce the burden of physical co-morbidity and lead to improved health outcomes are still in their infancy but growing at a reassuringly fast rate. This editorial considers the existing evidence base and makes suggestions for the development and future direction of this urgent research agenda and how this knowledge can be implemented in clinical practice.

Specific lysis of noradrenergic synaptosomes by an antiserum to dopamine-beta-hydroxylase.

An antiserum to dopamine-beta-hydroxylase purified from bovine adrenal medulla, acting in the presence of complement, caused the release of 12% of lactate dehydrogenase, 20% of tyrosine hydroxylase activity, and 40% of noradrenaline (NA) content from synaptosomes prepared from rat brain cerebral cortex. Uptake of [3H]NA was reduced by 54%. Anti-serum alone or complement alone were without action. The antiserum plus complement had no effect on choline uptake and did not release choline acetyltransferase, glutamate decarboxylase, dopamine or 5-hydroxytryptamine. These results suggest selective lysis of noradrenergic terminals had occurred. An enhancement of lysis was not observed when synaptosomes were stimulated with 75 mequiv./lK+ and exposed to a sub-maximal dose of antiserum, plus complement.

Specific lysis of GABAergic synaptosomes by an antiserum to glutamate decarboxylase.

An antiserum to pure glutamate decarboxylase (GAD) when incubated with rat cortical synaptosomes in the presence of complement caused release of 33-53% of lactate dehydrogenase (LDH) and 22-41% of total GAD. In addition most of the gamma-aminobutyrate (GABA) present was released. Anti-GAD antiserum alone, or complement alone, were without action. The antiserum plus complement had no effect on noradrenaline or choline uptake, and did not release choline acetylase (ChAT). Anti-ChAT serum plus complement released 30-37% of ChAT and 10-13% of LDH. It prevented choline uptake. This serum did not produce GAD release or prevent GABA, choline or noradrenaline uptake. When cortical synaptosomes were exposed to both antisera plus complement, their actions were strictly additive. The data indicate specific lysis of GABAergic and cholinergic synaptosomal sub-populations.

Specific immunolysis of serotonergic nerve terminals using an antiserum against tryptophan hydroxylase.

An antiserum to tryptophan hydroxylase purified from whole rat brain when incubated with rat striatal synaptosomes in the presence of complement caused release of 18% of LDH, 20% loss of potassium and 60% loss of tryptophan hydroxylase. Uptake of 5-HT was reduced by 60%. Anti-tryptophan hydroxylase alone, or complement alone were without action. The antiserum plus complement had no effect on DA uptake and did not release TH or GAD. These results suggest selective lysis of serotonergic nerve terminals had occurred. The antiserum plus complement reduced choline uptake by 45%. However, this did not seem due to lysis of cholinergic terminals, as ChAT was not released.

Plasma thiamin pyrophosphate and erythrocyte transketolase in chronic alcoholism.

Thiamin status in patients with an alcohol problem was studied before and after intramuscular thiamin hydrochloride. Results for erythrocyte transketolase activity and plasma thiamin pyrophosphate are compared. Plasma thiamin pyrophosphate values for healthy human subjects are reported for the first time. Advantages of plasma thiamin pyrophosphate in the assessment of thiamin status of patients are discussed.

Choline acetyltransferase in mammalian synaptosomes: Evidence for an integral membrane-bound form.

Choline acetyltransferase activity was detected in extensively washed membranes prepared from rat and guinea pig synaptosomes. When these preparations were treated with the non-ionic detergent Triton X-114 and heated to 37 degrees C to cause phase separation, a significant percentage was found to associate with the detergent-rich phase, indicating that the enzyme might be an integral membrane-bound protein. In guinea pigs receiving septal lesions, a large reduction in both total and in Triton X-114-extractable choline acetyltransferase in hippocampal synaptosomes was observed indicating that the detergent-extracted form is associated with cholinergic nerve terminals. When membrane-bound choline acetyltransferase from lysed, washed synaptosomes was incubated in Triton X-114, 30% of the membrane-associated enzyme could be extracted into the detergent-rich phase. This extraction could be improved by reducing the chloride content of the extraction medium. When the chloride content of synaptosomes, prepared from rat cerebral cortex, was manipulated, by either exposure to ?-aminobutyric acid, muscimol or to a medium containing reduced levels of chloride, the ability of antibodies against choline acetyltransferase to specifically immunolyse (in the presence of complement) the cholinergic synaptosome population was enhanced. These results suggest that the choline acetyltransferase found in the nerve terminal region exists in at least two forms (a soluble and a lipophilic form) which are partially interconvertible. The conversion between the two forms can be influenced by chloride ions.

Evidence for specific immunolysis of nerve terminals using antisera against choline acetyltransferase, glutamate decarboxylase and tyrosine hydroxylase.

Synaptosomes prepared from striatum or cerebral cortex of rat brain were incubated with antibodies raised against three neurotransmitter biosynthetic enzymes, choline acetyltransferase, glutamate decarboxylase and tyrosine hydroxylase in the presence or absence of complement. Immunolysis was first assessed by measuring the release of lactic dehydrogenase or reduction in potassium from synaptosomes, and lysis of neurochemically specific subpopulation of synaptosomes was detected by measuring release of either transmitters, their biosynthetic enzymes or by blockade of sodium-dependent uptake of transmitter or precursor. In both striatum and cortex, antibodies to choline acetyltransferase lysed only cholinergic while those against glutamate decarboxylase only lysed GABAergic nerve terminals. Antibodies against tyrosine hydroxylase lysed only the dopaminergic terminals in striatum but not noradrenergic terminals in cortex. The lysis occurred only in the presence of complement, and was never observed in the absence of complement. The studies indicate that antibodies to the neurotransmitter biosynthetic enzymes recognize antigens in the synaptosomal membrane specific only to neurons harboring the transmitters. The results suggest that the antibody-positive peptides in the membrane and neurotransmitter biosynthetic enzyme share common antigenic sites, probably common peptides.

Evidence for the presence of antibodies to cholinergic neurons in the serum of patients with Alzheimer's disease.

A blind study showing that serum from patients with Alzheimer's disease causes immunolysis of mammalian brain synaptosomes is reported. Control, aged-matched, sera were largely without effect. The immunolysis was directed mainly against cholinergic synaptosomes. The data presented support the hypothesis that autoimmune mechanisms may operate in the pathogenesis of Alzheimer's disease.

A cell-surface antigen of cholinergic nerve terminals recognized by antisera to choline acetyltransferase.

An antiserum to choline acetyltransferase, partially purified from bovine brain (anti-ChAT 1), when incubated with synaptosomes prepared from rat cerebral cortex in the presence of complement caused release of 10% of lactate dehydrogenase and 27% of ChAT. Sodium-dependent uptake of choline was totally abolished. Similar results were obtained when an antiserum to ChAT highly purified from pig brain (anti-ChAT 2) was used under similar conditions. These treatments had no effect on noradrenaline uptake and did not release glutamate decarboxylase. The results suggest selective lysis of cholinergic synaptosomes had occurred. A similar selective lysis was also observed when synaptosomes prepared from guinea pig cerebral cortex were used. Anti-ChAT 2 also inhibited choline uptake in a complement-independent manner.

Membrane-bound choline acetyltransferase is a cell surface marker of the differentiated NS-20Y cholinergic cell line.

When differentiated cells of the cholinergic NS-20Y type were incubated with an antiserum to choline acetyltransferase (ChAT), in the presence of complement, immunolysis occurred as demonstrated by release of 20% of total lactate dehydrogenase and 70% of total ChAT. No significant immunolytic effects were observed when either undifferentiated (dividing or non-dividing) or partially differentiated cells were incubated under identical conditions. When the Triton X-114 phase separation technique was employed using membranes from differentiated cells, a small but significant proportion of choline acetyltransferase was recovered in the detergent-rich phase. These results suggest that a membrane-bound form of ChAT is a surface marker of the NS-20Y cell line.

The preparation of highly purified GABAergic and cholinergic synaptosomes from mammalian brain.

Highly purified and metabolically viable gamma-aminobutyric acid (GABA)ergic and cholinergic synaptosomes were prepared from mammalian brain using antisera raised against glutamate decarboxylase and choline acetyltransferase respectively. These antisera appear to recognise specific outwardly facing components of GABAergic and cholinergic synaptic plasma membranes, as well as the specific neurotransmitter-synthesizing enzymes contained within the particular nerve terminal. After cell surface labelling had occurred, synaptosomes were incubated with magnetic microspheres which had previously been coupled with protein A. Labelled synaptosomes were then retrievable in a magnetic field. This separation technique allowed mg quantities of purified-synaptosomes to be prepared which contained less than 2% non-specific contaminants.

Outbreaks of the winter moth on Sitka Spruce in Scotland are not influenced by nutrient deficiencies of trees, tree budburst, or pupal predation.

Since the early 1980s, the winter moth, Operophtera brumata L. (Lepidoptera: Geometridae) has emerged as a serious pest of Sitka Spruce, Picea sitchensis Bong. plantations in southern Scotland. Outbreaks are characterised by susceptible sites within plantations which can occur immediately adjacent to resistant sites. We investigated the level of some nutrients in the trees, the date of budburst of the trees, and the numbers of some potential predators of winter moth pupae. None could satisfactorily explain outbreak patterns. Although foliage analysis demonstrated that many trees were marginal or deficient in phosphorus, nitrogen and potassium, these deficiencies were not related to the susceptibility of a site. Within sites, the numbers and weights of O. brumata were positively related to phosphorus content and negatively related to calcium content of foliage. Other evidence suggests, however, that these correlations may not represent direct effects of phosphorus and calcium on larval growth and survival. Date of budburst, which commonly determines susceptibility of deciduous hosts to O. brumata, was unrelated to density, and pupal predators were more, not less, abundant in susceptible sites. Although it is difficult to distinguish between factors that initiate outbreaks and those that maintain them, these data suggest that nutrient deficiencies of trees, budburst date, and the distribution of pupal predators of the winter moth cannot explain patterns of outbreak of the winter moth on spruce.

Antibodies in serum of patients with Alzheimer's disease cause immunolysis of cholinergic nerve terminals from the rat cerebral cortex.

A blind study showing that serum from patients with Alzheimer's disease causes immunolysis of mammalian brain synaptosomes is reported. Control, aged-matched, sera were largely without effect. The immunolysis was directed mainly against cholinergic synaptosomes. The data support the hypothesis that autoimmune mechanisms may operate in the pathogenesis of Alzheimer's disease.

Co-release of glutamate and aspartate from cholinergic and GABAergic synaptosomes.

Glutamate and aspartate are known to be released in a calcium-dependent fashion by depolarizing stimulation of mammalian brain synaptosomes (isolated nerve endings), an observation which strengthens their claims to be neurotransmitter candidates. The source of these compounds has been interpreted as the exclusively glutamatergic or aspartatergic synaptosome sub-populations assumed to be present in the standard heterogeneous preparations from mammalian brain. Several neurotransmitter-specific synaptosomal surface markers have recently been identified by immunolysis studies and these have allowed separation of subpopulations of synaptosomes by an affinity purification method. These markers appear to be closely related to the biosynthetic enzyme for the principal neurotransmitter released by each sub-category of synaptosome. We have isolated highly purified, metabolically active, GABAergic and cholinergic synaptosomes from cerebral cortex using antisera recognizing either glutamate decarboxylase (GAD) or choline acetyltransferase (ChAT), in conjunction with magnetic microspheres covalently coupled to Protein A (ref. 8), and now report that these synaptosomes release both glutamate and aspartate, in addition to their principal neurotransmitter, when treated with chemical depolarizing agents.

A species-specific repetitive sequence in Mycobacterium leprae DNA.

A 2.2-kilobase Mycobacterium leprae DNA insert fragment from a recombinant genomic library (pYA1065) was found to hybridize to at least 19 fragments of chromosomal M. leprae DNA by Southern hybridizations. The probe hybridized to identical fragments of chromosomal DNA from four M. leprae isolates (two from patients with leprosy, one from a naturally infected armadillo, and one from a naturally infected Mangabey monkey) whether the chromosomal DNA was digested with BamHI, BstEII, PstI, or SacI. The pYA1065 probe is specific for M. leprae; it did not hybridize to chromosomal DNA from 14 cultivable slow- and fast-growing mycobacterial species. Dot-blot hybridizations between pYA1065 and purified M. leprae chromosomal DNA indicate that the probe can detect DNA equivalent to 4 x 10(3) M. leprae cells in a spot. The probe can also hybridize to DNA in M. leprae cells spotted on a filter from homogenized skin biopsy specimens from patients with lepromatous leprosy.

GABAergic growth cones: release of endogenous gamma-aminobutyric acid precedes the expression of synaptic vesicle antigens.

Growth cone fractions isolated from neonatal [postnatal day 3 (P3)] rat forebrain contain GABAergic growth cones as demonstrated by immunofluorescence staining with monospecific antibodies to gamma-aminobutyric acid (GABA). HPLC analysis shows that GABAergic growth cones release this endogenous GABA when stimulated with high K+. Endogenous GABA release is Ca2(+)-independent and, in this respect, similar to that seen previously with [3H]GABA. Isolated growth cone fractions also exhibit a K(+)-stimulated, Ca2(+)-independent release of endogenous taurine. None of the other amino acids shown to be present in isolated growth cone fractions were released, including glutamate, aspartate, and glycine. A population of dissociated cerebral cortical neurones prepared from P1 rat forebrain were GABA-immunoreactive after 1 day in culture. The cell body, neurites, and growth cones of these neurones were all stained with GABA antibodies. At this time in culture, neurones did not stain with either of two antibodies to synaptic vesicle antigens, i.e., p65 and synaptophysin. Growth cones isolated from P3 rat forebrain were also not immunoreactive with these antibodies. After about 8 days in culture, when neurones had established extensive networks of long, varicose axons and elaborately branched dendrites, many neurones and their neurites were immunoreactive for GABA antibodies. At this time in culture, p65 and synaptophysin antibodies did stain neuronal cell bodies and particularly their varicose axons. Dendrites were not stained with synaptic vesicle antibodies. These results suggest that GABAergic neurones synthesize GABA during neurite outgrowth and that GABA is present in, and can be released from, the growth cones of these neurones. The presence of GABA in GABAergic growth cones is not associated with synaptic vesicles, which explains the Ca2+ independency of both endogenous and [3H]GABA release from these growth cones.

U1 small nuclear RNA-like sequences in human high molecular weight RNA.

Human U1 small nuclear RNA synthesis was shown earlier to be very sensitive to UV radiation. This led us to test for the possible presence of U1 RNA-like sequences in large RNAs. Human RNA was analyzed in gel blots hybridized with U1 DNA probes. A high molecular weight, heterodisperse RNA population was detected, which hybridizes both to a U1 RNA-coding region single-stranded DNA probe, and to a U1 gene fragment that contains only 6 nucleotides of flanking sequence. These large RNAs can be hybrid selected using immobilized U1 DNA, and have an average size of several kilobases. Additional observations support the claims that the high molecular weight RNA hybridization signal is not an aggregation artifact and that it is sequence specific.