Comparative analysis of anticholinergic burden scales to explain iatrogenic cognitive impairment in schizophrenia: results from the multicenter FACE-SZ cohort.

Aim: The anticholinergic properties of medications are associated with poorer cognitive performance in schizophrenia. Numerous scales have been developed to assess anticholinergic burden and yet, there is no consensus indicating which anticholinergic burden scale is more relevant for patients with schizophrenia. We aimed to identify valid scales for estimating the risk of iatrogenic cognitive impairment in schizophrenia. Methods: We identified 27 scales in a literature review. The responses to neuropsychological tests of 839 individuals with schizophrenia or schizoaffective disorder in the FACE-SZ database were collected between 2010 and 2021. We estimated the association between objective global cognitive performance and the 27 scales, the number of psychotropic drugs, and chlorpromazine and lorazepam equivalents in bivariable regressions in a cross-sectional design. We then adjusted the bivariable models with covariates: the predictors significantly associated with cognitive performance in multiple linear regressions were considered to have good concurrent validity to assess cognitive performance. Results: Eight scales, the number of psychotropic drugs, and drug equivalents were significantly associated with cognitive impairment. The number of psychotropic drugs, the most convenient predictor to compute, was associated with worse executive function (Standardized ß = -0.12, p = .004) and reasoning (Standardized ß = -0.08, p = .037). Conclusion: Anticholinergic burden, the number of psychotropic drugs, and drug equivalents were weakly associated with cognition, thus suggesting that cognitive impairment in schizophrenia and schizoaffective disorder is explained by factors other than medication. The number of psychotropic drugs was the most parsimonious method to assess the risk of iatrogenic cognitive impairment.

O-GlcNAcylation levels remain stable regardless of the anaesthesia in healthy rats.

Anaesthetics are used daily in human and veterinary medicine as well as in scientific research. Anaesthetics have an impact on cell homeostasis especially through modulation of protein post-translational modifications. O-GlcNAcylation, a ubiquitous post-translational modification, plays a role in many biological processes. The aims of this study were to evaluate whether (1) anaesthesia influences O-GlcNAcylation and (2) its stimulation affects physiological parameters. Male Wistar rats (n = 38) were anaesthetized with ketamine-xylazine or isoflurane. They randomly received either an intravenous injection of Ringer's lactate or NButGT (10mg/kg) in order to increase O-GlcNAcylation levels. One hour after induction of anaesthesia, haemodynamic parameters and plasmatic markers were evaluated. Heart, brain and lungs were harvested and O-GlcNAcylation levels and O-GlcNAc-related enzymes were evaluated by western blot. Cardiac and pulmonary O-GlcNAcylation levels and cardiac, cerebral and pulmonary O-GlcNAc associated enzyme expression were not impacted with anaesthesia. Compared with ketamine-xylazine, isoflurane had a lower impact on blood pressure, heart rate and glycaemia. Pharmacological stimulation of O-GlcNAcylation by NButGT did not affect the physiological parameters. This study offers unprecedented insights into the regulation of O-GlcNAcylation and O-GlcNAc related enzymes during anaesthesia. Pharmacological stimulation of O-GlcNAcylation over a 1-h period did not disrupt the physiological balance in healthy anaesthetized rats.

A new synthetic route towards multifunctionalized cyclic amidrazones for feeding chemical space.

In the context of growing impetus to develop new molecular scaffolds as well as a variety of 3D fragments to escape from flatland, we have reintroduced the accessibility of the underexplored azaheterocyclic amidrazones as promising bioisosteres. Herein, we present an original and versatile approach to synthesize cyclic amidrazones functionalized at different positions of the scaffold in view of diversifying the substitution pattern towards multifunctionalization, extension or fusion of the ring system and 3D-shaping of fragments. This unprecedented synthetic route represents a sweet achievement to cover further lead-like chemical space.

Clickable Dynamic Bioinks Enable Post-Printing Modifications of Construct Composition and Mechanical Properties Controlled over Time and Space.

Bioprinting is a booming technology, with numerous applications in tissue engineering and regenerative medicine. However, most biomaterials designed for bioprinting depend on the use of sacrificial baths and/or non-physiological stimuli. Printable biomaterials also often lack tunability in terms of their composition and mechanical properties. To address these challenges, the authors introduce a new biomaterial concept that they have termed "clickable dynamic bioinks". These bioinks use dynamic hydrogels that can be printed, as well as chemically modified via click reactions to fine-tune the physical and biochemical properties of printed objects after printing. Specifically, using hyaluronic acid (HA) as a polymer of interest, the authors investigate the use of a boronate ester-based crosslinking reaction to produce dynamic hydrogels that are printable and cytocompatible, allowing for bioprinting. The resulting dynamic bioinks are chemically modified with bioorthogonal click moieties to allow for a variety of post-printing modifications with molecules carrying the complementary click function. As proofs of concept, the authors perform various post-printing modifications, including adjusting polymer composition (e.g., HA, chondroitin sulfate, and gelatin) and stiffness, and promoting cell adhesion via adhesive peptide immobilization (i.e., RGD peptide). The results also demonstrate that these modifications can be controlled over time and space, paving the way for 4D bioprinting applications.

Family psychoeducation to improve outcome in caregivers and patients with schizophrenia: a randomized clinical trial.

Introduction: Schizophrenia is recognized for its severe impact on both patients and caregivers. In a 12-month follow-up randomized clinical trial, we aimed to measure the efficacy of a brief family psychoeducation program in terms of reducing relapse risk and improving medication adherence in patients, as well as reducing caregiver burden, depression and increasing knowledge of the illness. Methods: A total of 25 days of patients with schizophrenia (DSM-IV-TR) and family primary caregivers were recruited in a single regional psychiatric outpatient facility located in Bordeaux. In the active group, caregivers received a psychoeducational intervention consisting of six sessions spread over 1.5 months, while the control group was placed on a waiting list. Sociodemographic, symptom severity (PANSS) and medication adherence (MARS) from patients were assessed at baseline and relapse rates was recorded during the 12 months follow-up period. Caregivers' burden (ZBI), depression (CES-D), quality of life (S-CGQoL), knowledge of the disease (KAST) and therapeutic alliance (4PAS-C) were assessed at baseline, three and 6 months. Results: On the 25 patients included, the mean age was 33.3 years (SD = 9.7) with a mean duration of disease of 7.48 years (SD = 7.1). On the 25 caregivers included, the mean age was 50.6 years (SD = 14.0). Twenty-one were female (84.0%), 12 were married (48.0%) and 11 lived alone (44.0%). For patients, the family psychoeducation intervention significantly reduced the risk of relapse with a significant effect found at 12 months follow-up (p = 0.014). No change was observed on medication adherence. For caregivers, the intervention reduced the burden (p = 0.031), decreased the depression (p = 0.019), and increased the knowledge on schizophrenia (p = 0.024). Analyzes for repeated measures showed a statistically significant difference in therapeutic alliance (p = 0.035). Conclusion: As confirmed by previous studies, the brief multifamily program (consisting of six sessions over a period of 1.5 months) was found to be effective in improving outcomes for caregivers (e.g., burden, depression, knowledge) and patients (e.g., preventing relapse) in the context of routine care. Given its short duration, this program is expected to be easily implementable within the community. Clinical trial registration: https://clinicaltrials.gov/, NCT03000985.

EPAC1 Pharmacological Inhibition with AM-001 Prevents SARS-CoV-2 and Influenza A Virus Replication in Cells.

The exceptional impact of the COVID-19 pandemic has stimulated an intense search for antiviral molecules. Host-targeted antiviral molecules have the potential of presenting broad-spectrum antiviral activity and are also considered as less likely to select for resistant viruses. In this study, we investigated the antiviral activity exerted by AM-001, a specific pharmacological inhibitor of EPAC1, a host exchange protein directly activated by cyclic AMP (cAMP). The cAMP-sensitive protein, EPAC1 regulates various physiological and pathological processes but its role in SARS-CoV-2 and influenza A virus infection has not yet been studied. Here, we provide evidence that the EPAC1 specific inhibitor AM-001 exerts potent antiviral activity against SARS-CoV-2 in the human lung Calu-3 cell line and the African green monkey Vero cell line. We observed a concentration-dependent inhibition of SARS-CoV-2 infectious viral particles and viral RNA release in the supernatants of AM-001 treated cells that was not associated with a significant impact on cellular viability. Furthermore, we identified AM-001 as an inhibitor of influenza A virus in Calu-3 cells. Altogether these results identify EPAC1 inhibition as a promising therapeutic target against viral infections.

Beneficial Effects of O-GlcNAc Stimulation in a Young Rat Model of Sepsis: Beyond Modulation of Gene Expression.

The young population, which is particularly at risk of sepsis, is, paradoxically, rarely studied. Acute stimulation of O-GlcNAcylation, a post-translational modification involved in metabolic regulation, cell survival and stress response, is beneficial in young rats with sepsis. Considering that sepsis impacts the gene expression profile and that O-GlcNAcylation is a regulator of transcription, the aims of this study are to (i) unveil beneficial mechanisms of O-GlcNAcylation and (ii) decipher the relationship between O-GlcNAcylation and transcription during sepsis. Endotoxemic challenge was induced in 28-day-old male rats using a lipopolysaccharide injection (E. coli O111:B4, 20 mg·kg−1) and compared to control rats (NaCl 0.9%). One hour after, rats were assigned to no therapy or fluidotherapy (NaCl 0.9%, 10 mL.kg−1) ± NButGT (10 mg·kg−1) to stimulate O-GlcNAc levels. Cardiac O-GlcNAcylation levels were evaluated via Western blot and gene transcription using 3' SRP analysis. Lipopolysaccharide injection favorizes inflammatory state with the overexpression of genes involved in the NF-κB, JAK/STAT and MAPK pathways. NButGT treatment increased cardiac O-GlcNAcylation levels (p < 0.05). Yet, the mRNA expression was not impacted two hours after fluidotherapy or NButGT treatment. In conclusion, O-GlcNAc stimulation-induced beneficial effects are not dependent on the gene expression profile at the early phase of sepsis.

Thorough investigation of non-volatile substances extractible from inner coatings of metallic cans and their occurrence in the canned vegetables.

Since the decline of the use of bisphenol A, the chemistry of the varnishes and coatings which are applied to the inner surfaces of metallic food contact materials is poorly documented. We hypothesised that can coatings are now diverse and bring forth various non-intentionally added substances (NIAS) to be described. Investigating complex components such as NIAS requires demanding non-targeted approaches. We investigated the coatings of 12 vegetable cans from the French market. More than 125 substances were pinpointed, among them 84 oligoester combinations from 8 diols and 4 diacids. Thus, oligoesters were the dominant family. Additives such as epoxidised soybean oil, bisphenol A diglycidyl ether and benzoguanamine derivatives and phenol-formaldehyde oligomers were also identified. A software for exploring databases of theoretical combinations of polyester and phenol-formaldehyde resin components (NIAS-db 1.0) was made available. The stepwise organic synthesis of native and deuterated combinations of neopentyl glycol and isophthalic acid (4 and 8 units, linear and cyclic) enabled a higher confidence level and monitoring in vegetable extracts. Migration of oligoesters averaged 330 µg/kg in the drained vegetables (43-1600 µg/kg). This study sheds light on the need to fulfil a proper risk assessment on this NIAS family (exposure and hazard characterisation).

Synthesis of novel C-nucleoside analogues bearing an anomeric cyano and a 1,2,3-triazole nucleobase as potential antiviral agents.

A linear sequence to access a novel series of C-nucleosides bearing a quaternary carbon at the anomeric position tethered to a 4-substituted 1,2,3-triazole ring is described. Most of the compounds were obtained from a C-1 alkynyl furanoside, by a tandem or two-step CuAAC/functionalisation sequence, along with a diastereoselective cyanation of the furanoside derivatives in acidic conditions.

An O-GlcNAcylomic Approach Reveals ACLY as a Potential Target in Sepsis in the Young Rat.

Sepsis in the young population, which is particularly at risk, is rarely studied. O-GlcNAcylation is a post-translational modification involved in cell survival, stress response and metabolic regulation. O-GlcNAc stimulation is beneficial in adult septic rats. This modification is physiologically higher in the young rat, potentially limiting the therapeutic potential of O-GlcNAc stimulation in young septic rats. The aim is to evaluate whether O-GlcNAc stimulation can improve sepsis outcome in young rats. Endotoxemic challenge was induced in 28-day-old rats by lipopolysaccharide injection (E. Coli O111:B4, 20 mg·kg-1) and compared to control rats (NaCl 0.9%). One hour after lipopolysaccharide injection, rats were randomly assigned to no therapy, fluidotherapy (NaCl 0.9%, 10 mL·kg-1) ± NButGT (10 mg·kg-1) to increase O-GlcNAcylation levels. Physiological parameters and plasmatic markers were evaluated 2h later. Finally, untargeted mass spectrometry was performed to map cardiac O-GlcNAcylated proteins. Lipopolysaccharide injection induced shock with a decrease in mean arterial pressure and alteration of biological parameters (p < 0.05). NButGT, contrary to fluidotherapy, was associated with an improvement of arterial pressure (p < 0.05). ATP citrate lyase was identified among the O-GlcNAcylated proteins. In conclusion, O-GlcNAc stimulation improves outcomes in young septic rats. Interestingly, identified O-GlcNAcylated proteins are mainly involved in cellular metabolism.

Protein O-GlcNAcylation levels are regulated independently of dietary intake in a tissue and time-specific manner during rat postnatal development.

AIM: Metabolic sources switch from carbohydrates in utero, to fatty acids after birth and then a mix once adults. O-GlcNAcylation (O-GlcNAc) is a post-translational modification considered as a nutrient sensor. The purpose of this work was to assess changes in protein O-GlcNAc levels, regulatory enzymes and metabolites during the first periods of life and decipher the impact of O-GlcNAcylation on cardiac proteins. METHODS: Heart, brain and liver were harvested from rats before and after birth (D-1 and D0), in suckling animals (D12), after weaning with a standard (D28) or a low-carbohydrate diet (D28F), and adults (D84). O-GlcNAc levels and regulatory enzymes were evaluated by western blots. Mass spectrometry (MS) approaches were performed to quantify levels of metabolites regulating O-GlcNAc and identify putative cardiac O-GlcNAcylated proteins. RESULTS: Protein O-GlcNAc levels decrease drastically and progressively from D-1 to D84 (13-fold, P < .05) in the heart, whereas the changes were opposite in liver and brain. O-GlcNAc levels were unaffected by weaning diet in any tissues. Changes in expression of enzymes and levels of metabolites regulating O-GlcNAc were tissue-dependent. MS analyses identified changes in putative cardiac O-GlcNAcylated proteins, namely those involved in the stress response and energy metabolism, such as ACAT1, which is only O-GlcNAcylated at D0. CONCLUSION: Our results demonstrate that protein O-GlcNAc levels are not linked to dietary intake and regulated in a time and tissue-specific manner during postnatal development. We have identified by untargeted MS putative proteins with a particular O-GlcNAc signature across the development process suggesting specific role of these proteins.

Gap-134, a Connexin43 activator, prevents age-related development of ventricular fibrosis in Scn5a+/- mice.

Down-regulation of Connexin43 (Cx43) has often been associated with the development of cardiac fibrosis. We showed previously that Scn5a heterozygous knockout mice (Scn5a+/-), which mimic familial progressive cardiac conduction defect, exhibit an age-dependent decrease of Cx43 expression and phosphorylation concomitantly with activation of TGF-ß pathway and fibrosis development in the myocardium between 45 and 60 weeks of age. The aim of this study was to investigate whether Gap-134 prevents Cx43 down-regulation with age and fibrosis development in Scn5a+/- mice. We observed in 60-week-old Scn5a+/- mouse heart a Cx43 expression and localization remodeling correlated with fibrosis. Chronic administration of a potent and selective gap junction modifier, Gap-134 (danegaptide), between 45 and 60 weeks, increased Cx43 expression and phosphorylation on serine 368 and prevented Cx43 delocalization. Furthermore, we found that Gap-134 prevented fibrosis despite the persistence of the conduction defects and the TGF-ß canonical pathway activation. In conclusion, the present study demonstrates that the age-dependent decrease of Cx43 expression is involved in the ventricular fibrotic process occurring in Scn5a+/- mice. Finally, our study suggests that gap junction modifier, such as Gap-134, could be an effective anti-fibrotic agent in the context of age-dependent fibrosis in progressive cardiac conduction disease.

Second Coordination Sphere Effects in an Evolved Ru Complex Based on Highly Adaptable Ligand Results in Rapid Water Oxidation Catalysis.

A new Ru complex containing the deprotonated 2,2':6',2''-terpyridine-6,6''-diphosphonic acid (H4tPa) and pyridine (py) of general formula [RuII(H3tPa-κ-N3O)(py)2]+, 2+, has been prepared and thoroughly characterized by means of spectroscopic and electrochemical techniques, X-ray diffraction analysis, and density functional theory (DFT) calculations. Complex 2+ presents a dynamic behavior in the solution that involves the synchronous coordination and the decoordination of the dangling phosphonic groups of the tPa4- ligand. However, at oxidation state IV, complex 2+ becomes seven coordinated with the two phosphonic groups now bonded to the metal center. Further, at this oxidation state at neutral and basic pH, the Ru complex undergoes the coordination of an exogenous OH- group from the solvent that leads to an intramolecular aromatic O atom insertion into the CH bond of one of the pyridyl groups, forming the corresponding phenoxo-phosphonate Ru complex [RuIII(tPaO-κ-N2OPOC)(py)2]2-, 42-, where tPaO5- is the 3-(hydroxo-[2,2':6',2''-terpyridine]-6,6''-diyl)bis(phosphonate) ligand. This new in situ generated Ru complex, 42-, has been isolated and spectroscopically and electrochemically characterized. In addition, a crystal structure has been also obtained using single-crystal X-ray diffraction techniques. Complex 42- turns out to be an exceptional water oxidation catalyst achieving record maximum turnover frequencies (TOFmax) on the order of 16 000 s-1. A mechanistic analysis complemented with DFT calculations has also been carried out, showing the critical role of intramolecular second coordination sphere effects exerted by the phosphonate groups in lowering the activation energy at the rate-determining step.

Brief interventions for improving adherence in schizophrenia: A pilot study using electronic medication event monitoring.

Poor medication adherence remains frequent in schizophrenia. The present study examined the efficacy of two month-long pilot interventions using the Medication Event Monitoring System (MEMS®). Thirty-three outpatients at high risk for relapse were randomized to receive a smartphone-based intervention, a nurse-based intervention, or treatment as usual. All patients then used the MEMS® to objectively measure medication adherence over six months. No differences were observed in adherence measures or relapse rates across the three groups. When using electronic medication monitoring as an objective measure of adherence, easily-implemented interventions may not significantly improve adherence in patients at high risk for relapse.

3,4-Dideoxy-3,3,4,4-tetrafluoro- and 4-OH epimeric 3-deoxy-3,3-difluoro-α-GalCer analogues: Synthesis and biological evaluation on human iNKT cells stimulation.

iNKT cells recognize CD1d/α-galactosylceramide (α-GalCer) complexes via their invariant TCR receptor and stimulate the immune response. Many α-GalCer analogues have been investigated to interrogate this interaction. Following our previous work related to the modification of the hydrogen bond network between α-GalCer and CD1d, we have now focused our attention on the synthesis of 3-deoxy-3,3-difluoro- and 3,4-dideoxy-3,3,4,4-tetrafluoro-α-GalCer analogues, and studied their ability to stimulate human iNKT cells. In each case, deoxygenation at the indicated positions was accompanied by difluoro introduction in order to evaluate the resulting electronic effect on the stability of the ternary CD1d/Galcer/TCR complex which has been rationalized by modeling study. With deoxy-difluorination at the 3-position, the two epimeric 4-OH analogues were investigated to establish their capacity to compensate for the lack of the hydrogen bond donating group at the 3-position. The 3,4-dideoxytetrafluoro analogue was of interest to highlight the amide NH-bond hydrogen bond properties.

Prevalence of and Risk Factors for Extrapyramidal Side Effects of Antipsychotics: Results From the National FACE-SZ Cohort.

BACKGROUND: Extrapyramidal side effects (EPS) have been identified as a complication of antipsychotic treatment. Previous meta-analyses have investigated EPS prevalence and risk factors in randomized clinical trials with highly selected patients, but studies in real-world schizophrenia are missing. OBJECTIVE: To examine the prevalence and clinical correlates associated with EPS in a nonselected national multicenter sample of stabilized patients with schizophrenia. METHODS: Between 2010 and 2016, patients suffering from schizophrenia (DSM-IV-TR criteria) were recruited through the FondaMental Academic Centers of Expertise for Schizophrenia (FACE-SZ) network and data were collected during a comprehensive 1-day-long standardized evaluation. The Simpson-Angus Scale and the Abnormal Involuntary Movement Scale were used to assess drug-induced parkinsonism (DIP) and tardive dyskinesia, respectively. RESULTS: The overall prevalence of DIP and tardive dyskinesia was 13.2% and 8.3%, respectively, in this community-dwelling sample of 674 patients. DIP was associated with negative symptoms (Positive and Negative Syndrome Scale [PANSS] subscore) (adjusted odds ratio [aOR] = 1.102, P < .001), first-generation antipsychotic prescription (aOR = 2.038, P = .047), and anticholinergic drug administration (aOR = 2.103, P = .017) independently of sex, age, disorganization (PANSS disorganized factor), and antipsychotic polytherapy. Tardive dyskinesia was associated with PANSS disorganized factor (aOR = 1.103, P = .049) independently of sex, age, negative symptoms, excitation, first-generation antipsychotic prescription, and benzodiazepine and anticholinergic drug administration. CONCLUSIONS: Our results indicate the high prevalence of EPS in a nonselected community-dwelling clinically stable sample of outpatients with schizophrenia. In the monitoring of antipsychotic treatment, EPS should be systematically evaluated, especially when negative symptoms and disorganization or cognitive alteration are present. Monotherapy with a second-generation antipsychotic should be preferentially initiated for patients with these side effects.

Mediation Analyses of Insight, Quality of Life, Depression, and Suicidality: Results From the FACE-SZ Cohort.

OBJECTIVE: The relationship between greater insight and increased risk of suicide in patients with schizophrenia is debated. The purpose of this study was to assess whether quality of life (QoL) and depression mediated the association between insight and suicidality. METHODS: Between March 2010 and December 2015, 527 community-dwelling adults with stable schizophrenia according to DSM-IV criteria were included in a multicenter cross-sectional study, the FondaMental Academic Centers of Expertise for Schizophrenia (FACE-SZ) Study. Structural equation modeling was used for mediation analyses among insight, QoL, depression, and suicidality, controlling for the global level of schizophrenic symptoms. RESULTS: The model provided a good fit for the data (χ²3 = 1.4, P = .708, Tucker-Lewis index = 1, comparative fit index = 1, root mean square error of approximation = 0, standardized root mean square residual = 0.008) and explained 27% of the variance in suicidality. Poorer QoL and greater severity of depression mediated 68.4% of the positive association between insight and suicidality (full mediation). Poorer QoL mediated 48% of the positive effect of insight on depression (partial mediation). The severity of depression mediated 91.2% of the negative relationship between QoL and suicidality (full mediation). CONCLUSIONS: Insight appears to be an indirect risk factor for suicide in patients with schizophrenia, with the link being mediated by poorer QoL and worse underlying depression, mainly by a sequential pathway but also by a less important parallel pathway.

Evaluation of adherence patterns in schizophrenia using electronic monitoring (MEMS®): A six-month post-discharge prospective study.

BACKGROUND: Medication Event Monitoring System (MEMS®) is considered the gold standard for the evaluation of medication adherence, yet few studies have applied this method, especially over long periods of time. OBJECTIVE: To investigate medication adherence patterns in a sample of post-discharge patients with schizophrenia monitored with MEMS caps during a six-month period. METHOD: Adherence to antipsychotics was prospectively investigated using MEMS among 68 patients with schizophrenia. Treatment initiation, implementation or whether or not the patient takes his dosing regimen as prescribed, persistence or the length of time between initiation and discontinuation, and treatment discontinuation were used to describe adherence. Persistence over time was described using Kaplan-Meier curves. RESULTS: After discharge 16% of the patients never initiated treatment. On average 37.3% of patients adhered to treatment in the first 6months. However, a strong decrease in adherence was observed over time (p<0.0001), primarily due by treatment non-persistence. Only half of the patients were persistent at 6weeks, persistence further dropped to 19.0% after 6months. Among persistent patients, implementation was consistent over time with 87.8% of patients taking their medication as prescribed on any given day. CONCLUSIONS: Dosing profile analysis provides further evidence for the magnitude of non-adherence with antipsychotic prescriptions among post-discharge patients with schizophrenia. Using the high precision of MEMS®, dosing profiles may provide a better understanding of non-adherence patterns and help clinicians determine optimal individualized strategies.

Medication adherence in schizophrenia: The role of insight, therapeutic alliance and perceived trauma associated with psychiatric care.

Medication non adherence in schizophrenia is a major cause of relapse and hospitalization and remains for clinicians an important challenge. This study investigates the associations between insight, therapeutic alliance, perceived trauma related to psychiatric treatment and medication adherence in patients with schizophrenia. In this multicenter study, 72 patients were assessed regarding symptomatology, self-reported adherence with medication, insight, medication side-effects, therapeutic alliance and perceived trauma related to psychiatric treatment. Structural Equation Modeling (SEM) was used to test predicted paths among these variables. The data fit a model in which medication adherence was directly predicted by insight, therapeutic alliance and perceived trauma related to psychiatric treatment. Perceived trauma moderates the role of insight on medication adherence. The final model showed good fit, based on four reliable indices. Greater adherence was correlated with higher insight, higher therapeutic alliance and lower perceived trauma. These three variables appear to be important determinants of patient's medication adherence. Medication adherence could be enhanced by reducing perceived trauma and by increasing insight. The need for mental health providers to acknowledge patients' potentially traumatic experience with psychiatric treatment and the need to encourage greater involvement in care are discussed.