Yoga versus non-standard care for schizophrenia.

BACKGROUND: Yoga is an ancient spiritual practice that originated in India and is currently accepted in the Western world as a form of relaxation and exercise. It has been of interest for people with schizophrenia as an alternative or adjunctive treatment. OBJECTIVES: To systematically assess the effects of yoga versus non-standard care for people with schizophrenia. SEARCH METHODS: The Information Specialist of the Cochrane Schizophrenia Group searched their specialised Trials Register (latest 30 March 2017), which is based on regular searches of MEDLINE, PubMed, Embase, CINAHL, BIOSIS, AMED, PsycINFO, and registries of clinical trials. We searched the references of all included studies. There are no language, date, document type, or publication status limitations for inclusion of records in the register. SELECTION CRITERIA: All randomised controlled trials (RCTs) including people with schizophrenia and comparing yoga with non-standard care. We included trials that met our selection criteria and reported useable data. DATA COLLECTION AND ANALYSIS: The review team independently selected studies, assessed quality, and extracted data. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between groups and its 95% CI. We employed a fixed-effect models for analyses. We examined data for heterogeneity (I2 technique), assessed risk of bias for included studies, and created a 'Summary of findings' table for seven main outcomes of interest using GRADE (Grading of Recommendations Assessment, Development and Evaluation). MAIN RESULTS: We were able to include six studies (586 participants). Non-standard care consisted solely of another type of exercise programme. All outcomes were short term (less than six months). There was a clear difference in the outcome leaving the study early (6 RCTs, n=586, RR 0.64 CI 0.49 to 0.83, medium quality evidence) in favour of the yoga group. There were no clear differences between groups for the remaining outcomes. These included mental state (improvement in Positive and Negative Syndrome Scale, 1 RCT, n=84, RR 0.81 CI 0.62 to 1.07, low quality evidence), social functioning (improvement in Social Occupational Functioning Scale, 1 RCT, n=84, RR 0.90 CI 0.78 to 1.04, low quality evidence), quality of life (mental health) (average change 36-Item Short Form Survey (SF-36) quality-of-life sub-scale, 1 RCT, n=69, MD -5.30 CI -17.78 to 7.18, low quality evidence), physical health, (average change WHOQOL-BREF physical-health sub-scale, 1 RCT, n=69, MD 9.22 CI -0.42 to 18.86, low quality evidence). Only one study reported adverse effects, finding no incidence of adverse events in either treatment group. There were a considerable number of missing outcomes, which included relapse, change in cognition, costs of care, effect on standard care, service intervention, disability, and activities of daily living. AUTHORS' CONCLUSIONS: We found minimal differences between yoga and non-standard care, the latter consisting of another exercise comparator, which could be broadly considered aerobic exercise. Outcomes were largely based on single studies with limited sample sizes and short-term follow-up. Overall, many outcomes were not reported and evidence presented in this review is of low to moderate quality - too weak to indicate that yoga is superior or inferior to non-standard care control for management of people with schizophrenia.

A systematic review of treatments for post-traumatic stress disorder among refugees and asylum-seekers.

Recent years have seen a consensus emerge on the treatment of post-traumatic stress disorder (PTSD) in the general population. No such consensus exists for refugees, although the rate of PTSD among refugees is 10 times that of the general population. We conducted a systematic review of randomized controlled trial of treatment of PTSD among refugees and asylum-seekers. We rated trials with a risk of bias table and drew conclusions about the evidence for individual therapies. Ten randomized, controlled trials (n = 528) met our search criteria. Trials were small, and allocation concealment and blinding were inadequate. No treatment was firmly supported, but there was evidence for narrative exposure therapy and cognitive-behavioral therapy. Future trials should evaluate interventions that are developed within refugees' cultures, based on a local understanding of trauma and psychological distress.

Beyond the critical period: longitudinal study of 8-year outcome in first-episode non-affective psychosis.

BACKGROUND: The critical period hypothesis proposes that deterioration occurs aggressively during the early years of psychosis, with relative stability subsequently. Thus, interventions that shorten the duration of untreated psychosis (DUP) and arrest early deterioration may have long-term benefits. AIMS: To test the critical period hypothesis by determining whether outcome in non-affective psychosis stabilises beyond the critical period and whether DUP correlates with 8-year outcome; to determine whether duration of untreated illness (DUI) has any independent effect on outcome. METHOD: We recruited 118 people consecutively referred with first-episode psychosis to a prospective, naturalistic cohort study. RESULTS: Negative and disorganised symptoms improved between 4 and 8 years. Duration of untreated psychosis predicted remission, positive symptoms and social functioning at 8 years. Continuing functional recovery between 4 and 8 years was predicted by DUI. CONCLUSIONS: These results provide qualified support for the critical period hypothesis. The critical period could be extended to include the prodrome as well as early psychosis.

Refugees, the asylum system and mental healthcare in Ireland.

The number of people seeking refugee status in Ireland is increasing year on year and the burden of mental illness experienced by refugees and asylum seekers is high. The College of Psychiatrists of Ireland has recommended the establishment of a number of specialist refugee mental health teams. In this paper we discuss the Irish asylum system, the Irish evidence regarding mental illness in this population, and current health service policy regarding refugee mental health. We propose a model of specialist refugee mental healthcare delivery.

Prospective relationship of duration of untreated psychosis to psychopathology and functional outcome over 12 years.

BACKGROUND: The duration of untreated psychosis is well recognised as an independent predictor of symptomatic and functional outcome in the short term and has facilitated the development of worldwide early intervention programmes. However, the extent and mechanisms by which it might influence prognosis beyond a decade remain poorly understood. METHODS: The authors examined the relationship between duration of untreated psychosis and outcome 12years after a first episode of psychosis and assessed whether its relationship with function is affected by symptoms in a prospective, 12-year follow-up of an epidemiologically-based inception cohort. RESULTS: Longer duration of untreated psychosis predicted poorer remission status, more severe positive and negative symptoms, and greater impairment in general functioning, social functioning and quality of life at 12years on standardised measures, independent of other factors at baseline. It was not associated with gainful employment, for which education was the only predictor, or independent living, for which age was the only predictor. The relationship between duration of untreated psychosis and functional outcome was mediated by concurrent psychopathology, particularly negative symptoms. CONCLUSIONS: These results provide qualified support for the potential long-term benefit of reduction in the duration of untreated psychosis in terms of improvement in symptoms and functional outcome. Its failure to predict real-life outcomes such as independent living and gainful employment could reflect the importance of pre-existing socio-cultural factors such as individual opportunity. The relationship between duration of untreated psychosis and negative symptoms was largely responsible for its effect on function, suggesting a possible long-term protective mechanism against disability.

Post-traumatic stress disorder: present and future.

Post-traumatic stress disorder (PTSD) and acute stress disorder (ASD) differ from almost every other psychiatric diagnosis in that they may only be diagnosed with reference to an aetiological event - an external traumatic stressor. ASD occurs immediately after the stressor and is comparatively short-lived, while PTSD is a prolonged abnormal response that may take months to develop. The types of stressor leading to ASD and PTSD are identical and were intended to be tightly defined, involving a perceived threat of death, serious injury or loss of physical integrity. It is useful initially to distinguish ASD and PTSD from adjustment disorders, which are also diagnosed only after an observable life event. An adjustment disorder may be thought of as a gradual and prolonged response to stressful changes in a person's life. The range of stressors precipitating an adjustment disorder is potentially much broader than that precipitating ASD or PTSD, as a threat of death or injury is not needed. Indeed, a 'threat' as such is not needed, as the event may be a loss. Events such as job loss or the breakup of a relationship may lead to an adjustment disorder, as well as threats such as accidents or assaults. The diagnostic criteria for adjustment disorder do not specify what the immediate response, if any, to the precipitating stressor must be.

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL): a familial cause of depression and headache.

A 31 year-old man with a history of a depressive episode presented with acute severe 'thunderclap' headache. Magnetic resonance imaging (MRI) revealed abnormalities typical of cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL), which was subsequently confirmed by genetic analysis. The psychiatric features of this genetic cause of depression and headache are discussed.

The Myth of Mental Illness: 50 years after publication: What does it mean today?

In 1960, Thomas Szasz published The Myth of Mental Illness, arguing that mental illness was a harmful myth without a demonstrated basis in biological pathology and with the potential to damage current conceptions of human responsibility. Szasz's arguments have provoked considerable controversy over the past five decades. This paper marks the 50th anniversary of The Myth of Mental Illness by providing commentaries on its contemporary relevance from the perspectives of a range of stakeholders, including a consultant psychiatrist, psychiatric patient, professor of philosophy and mental health, a specialist registrar in psychiatry, and a lecturer in psychiatry. This paper also includes responses by Professor Thomas Szasz. Szasz's arguments contain echoes of positivism, Cartesian dualism, and Enlightenment philosophy, and point to a genuine complexity at the heart of contemporary psychiatric taxonomy: how is 'mental illness' to be defined? And by whom? The basis of Szasz's doubts about the similarities between mental and physical illnesses remain apparent today, but it remains equally apparent that a failure to describe a biological basis for mental illness does not mean there is none (eg. consider the position of epilepsy, prior to the electroencephalogram). Psychiatry would probably be different today if The Myth of Mental Illness had not been written, but possibly not in the ways that Szasz might imagine: does the relentless incarceration of individuals with 'mental illness' in the world's prisons represent the logical culmination of Szaszian thought? In response, Professor Szasz emphasises his views that "mental illness" differs fundamentally from physical illness, and that the principal habits the term 'mental illness' involves are stigmatisation, deprivation of liberty (civil commitment) and deprivation of the right to trial for alleged criminal conduct (the insanity defence). He links the incarceration of the mentally ill with the policy of de-institutionalisation (which he opposes) and states that, in his view, the only limitation his work imposes on human activities are limitations on practices which are conventionally and conveniently labelled 'psychiatric abuses'. Clearly, there remains a diversity of views about the merits of Szasz's arguments, but there is little diminution in his ability to provoke an argument.

Nonadherence to medication four years after a first episode of psychosis and associated risk factors.

OBJECTIVES: This study examined concurrent associations and predictors at first indication of nonadherence to antipsychotic medication four years after a first episode of psychosis. METHODS: A prospective cohort of 171 patients in urban Ireland with a first episode of psychosis was followed up four years after inception (follow-up primary analysis, N=84; secondary analysis, N=104). RESULTS: At the four-year follow-up 76% were adherent and 24% were not. Nonadherence was concurrently associated with substance misuse (p<.01), increased symptomatology (p<.01), less insight (p=.01), lower global functioning (p<.01), and negative attitudes toward medication (p<.01). Compared with other patients, those who were nonadherent had more readmissions (p=.01). Predictors of future nonadherence were substance misuse (p=.02) and duration of untreated psychosis (p=.04). CONCLUSIONS: This prospective investigation confirms previous cross-sectional studies. The association between longer duration of untreated psychosis and nonadherence warrants further research because it could be interpreted as further evidence of the importance of early intervention.

A little knowledge: caregiver burden in schizophrenia in Malawi.

OBJECTIVE: To determine the relationship between schizophrenia knowledge and burden of care among caregivers of people with schizophrenia in Mzuzu, Malawi. METHOD: We recruited 90 patients and 90 caregivers to a randomized, controlled trial of group caregiver education in schizophrenia. At baseline, we administered the Family Questionnaire, which measures caregivers' knowledge of biomedical and psychosocial aspects of schizophrenia. We measured caregiver burden with the Involvement Evaluation Questionnaire. Using multivariate analysis, we examined the relationship between knowledge and burden, controlling for other patient and caregiver variables. We hypothesised that knowledge and burden would be inversely related. RESULTS: Caregiver burden was associated with knowledge (p = 0.001), but contrary to our hypothesis, greater knowledge was associated with greater burden. CONCLUSION: In this population, knowledge about schizophrenia was associated with higher caregiver burden. This does not prove that knowledge causes burden, but suggests that cultural factors may mediate the relationship between knowledge and burden, and that care is needed when introducing caregiver education in new cultures.

Chitinase-3-like 1 (CHI3L1) gene and schizophrenia: genetic association and a potential functional mechanism.

BACKGROUND: Gene expression data and association analyses in two Chinese samples implicate chitinase 3-like 1 (CHI3L1), a cellular survival gene, in schizophrenia susceptibility. METHODS: We tested whether the association data are robust to replication in a Caucasian schizophrenia sample and performed a comprehensive investigation of common genetic variation at the locus. RESULTS: In a sample of 375 case and 812 control subjects we identified significant association with the same risk allele at the promoter single nucleotide polymorphism (SNP) associated in the original study (rs10399805; p = .018) and with another SNP at intron 7 of CHI3L1 (rs2275351; p = .008). The rs10399805 SNP is located at position -247 and disrupts the C/EBP-AML-1 binding site in the gene promoter; the risk allele is predicted to increase CHI3L1 expression, as has been reported in several postmortem schizophrenia studies. Carriers of the risk variant presented with fewer positive symptoms and relatively spared cognitive performance compared with other schizophrenia patients. CONCLUSIONS: These findings support a functional mechanism for involvement of CHI3L1 in schizophrenia susceptibility, possibly contributing to a less severe illness. The associated variants in this study are not well tagged by all Whole-Genome Association (WGA) platforms, suggesting additional genotyping may be necessary despite the imminent availability of WGA data from large SZ samples. Because CHI3L1 may be involved in transmission of stress-induced cellular responses, studies of interaction with known environmental risk factors may also be warranted.

Dysbindin (DTNBP1) and the biogenesis of lysosome-related organelles complex 1 (BLOC-1): main and epistatic gene effects are potential contributors to schizophrenia susceptibility.

BACKGROUND: The DTNBP1 gene, encoding dysbindin, has been strongly implicated in schizophrenia (SZ) susceptibility by a series of independent genetic association and gene expression studies. Among its known functions, dysbindin is part of a protein complex, termed the biogenesis of lysosome-related organelles complex 1 (BLOC-1), the molecular components of which might be involved in the regulation of vesicular trafficking and dendrite branching. METHODS: A systematic investigation of the other seven BLOC-1 genes (MUTED, PLDN, CNO, SNAPAP, BLOC1S1, BLOC1S2, and BLOC1S3) for evidence of association with SZ was undertaken in a sample of 373 SZ cases and 812 control subjects. Possible epistasis between combinations of BLOC-1 genes, including DTNBP1, was tested with a novel method of investigating for gene-gene interaction. Quality control measures were incorporated into genotyping strategy, and all results were corrected for multiple testing to prevent false positive results. RESULTS: We identified significant evidence of association between BLOC1S3 and SZ (odds ratio = 1.45, confidence interval = 1.13-1.86, p = .0028, corrected p = .0389). We also report evidence for epistatic interaction between DTNBP1 and MUTED contributing to SZ in the absence of a significant main effect at MUTED (p = .0009, corrected p = .0252). Single marker and epistasis results remained significant after correction for multiple testing. CONCLUSIONS: Together these data provide evidence for the involvement of the BLOC-1 protein complex in SZ pathogenesis.

Insight, psychopathology and global functioning in schizophrenia in urban Malawi.

Insight, psychopathology and functioning are related in schizophrenia, but it is unclear whether insight relates independently to functioning after controlling for psychopathology. Equally, any such relationship may vary culturally. We investigated the relationship between insight, psychopathology and functioning in 60 patients with schizophrenia in Mzuzu, a town in Malawi. After controlling for psychopathology, functioning was associated with the ;symptom relabelling' dimension of insight (P=0.01). This preliminary finding suggests that symptom-focused psychoeducation might be appropriate for African patients with schizophrenia.