Discordance between clinician-rated and patient-reported outcomes during 48-week community care for schizophrenia: longitudinal patterns and associations with insight

BackgroundRecovery in schizophrenia is multidimensional, but whether clinician-rated and patient-reported outcomes (PROs) improve concordantly during community care is unclear. We examined their longitudinal discordance and its association with insight and treatment attitudes.MethodsIn this secondary analysis of a 48-week, multicity, naturalistic cohort, 306 community-dwelling adults with schizophrenia in Guangdong, China, were assessed at baseline and weeks 12, 24, 36, and 48 using the Positive and Negative Syndrome Scale (PANSS), Personal and Social Performance Scale (PSP), Schizophrenia Quality of Life Scale (SQLS), and Insight and Treatment Attitudes Questionnaire (ITAQ). Changes in PANSS, PSP, and SQLS were standardized using baseline standard deviation (SD) units, with positive values indicating improvement. Study-defined symptom-PRO and function-PRO recovery gaps were estimated using mixed-effects models adjusted for age, sex, city, and baseline treatment pathway. A joint week-48 bootstrap test was conducted, and ITAQ was decomposed into within-person and between-person components.ResultsAt week 48, adjusted improvements were 0.30 SD for PANSS (95% CI, 0.23 to 0.37), 0.20 SD for PSP (95% CI, 0.12 to 0.28), and 0.46 SD for SQLS (95% CI, 0.37 to 0.54). The symptom-PRO gap was -0.16 SD (95% CI, -0.27 to -0.05), and the function-PRO gap was -0.26 SD (95% CI, -0.38 to -0.14), indicating greater patient-reported improvement than clinician-rated improvement (joint Q = 24.58, df = 2, p < 0.001). The gaps were evident from week 12; the symptom-PRO result was sensitive to city composition. At the 0.5-SD threshold, patient-reported-only improvement was more frequent than clinician-rated-only improvement for symptom-PRO (20.7% vs. 11.3%) and function-PRO (22.4% vs. 12.3%) comparisons. For each 1-SD occasion-specific increase in ITAQ, the gaps shifted 0.08 and 0.06 SD toward the clinician-rated direction, but the joint test was inconclusive (p = 0.064).ConclusionDuring routine community care, patient-reported quality of life improved more than clinician-rated psychopathology and social functioning, with the discrepancy larger and more robust for functioning. Parallel monitoring may better characterize symptom, function, and quality-of-life trajectories, while the role of time-varying insight and treatment attitudes warrants further study.

An Online Cross-Sectional Research Domain Criteria (RDoC) Positive Valence Assessment Study With Patients With a Severe Mental Illness: Methodological Evaluation

Background: Abnormal reward processing is considered a core feature of severe mental illness (SMI). Deficits in this domain can have severe implications for daily functioning. The Online Positive Valence Study aimed to assess reward processing in bipolar disorder and schizophrenia using the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) Positive Valence Systems (PVS) framework in an online task-based study. Recruitment and study adherence fell short of expectations. Objective: This paper critically evaluates the methodology used and shares the lessons learned from conducting an online task-based study of reward processing in a sample of patients with SMI. Methods: Using a cross-sectional design, the Online Positive Valence Study measured reward processing using 3 reward tasks, the monetary incentive delay task (MID), effort expenditure of rewards task (EEfRT), and a social and coin version of the Bandit task. Participants were eligible if they were 18 years or older. They were recruited mainly via email from 2 completed prospective cohorts. From 2023, the initial recruitment goal was no longer followed. Recruitment strategies and task performance are evaluated. Results: The sample consisted of 319 participants: 186 patients (58.3%), 81 first-degree relatives (25.4%), and 52 controls (16.3%). Multinomial logistic regression analyses revealed participants who were additionally called were more than 4 times more likely to respond “no” (odds ratio [OR] 4.57, 95% CI 3.12 to 6.70, <.001) and more than twice as likely to respond “yes” (OR 2.75, 95% CI 1.93 to 3.92, <.001) versus no response compared with those who received only emails. Personal salutations in invitation mails reduced the likelihood of participation compared to nonpersonal salutations (OR 0.31, 95% CI 0.20 to 0.47, <.001). Analyses of covariance (ANCOVAs) and linear mixed effects models (LLMs) revealed task performance was comparable between in-lab and online groups. Online participants showed longer reaction times on the MID task (=20.43, SE=2.55, =8.02, <.001) and lower win-stay rates on both Bandits (Bandit Coin: =–0.55, 95% CI –0.68 to –0.42, SE=0.06, =–8.73, <.001, η² =.14; Bandit Social: =–0.65, 95% CI –0.80 to –0.49, SE=0.08, =–8.54, <.001, η² =.14). Conclusions: For the first time, we performed a remote online task-based assessment of the PVS domain in patients with SMI, and we learned important lessons along the way. Future studies should carefully consider recruiting from existing cohorts; hire full-time dedicated personnel; and use personal approaches to recruitment, like phone calls, adjusting recruitment to the target population(s), and making participation technically as simple as possible. Attrition may be reduced by shortening the duration of participation and/or adding gamification. This study offers guidance for future research in online cognitive assessment in patients with SMI.

Understanding the role of dysfunctional hippocampal-parahippocampal representations of space in schizophrenia

The etiology of schizophrenia is yet to be fully understood, thus limiting the scope of interventions for symptom reduction. Among features less frequently researched and addressed are deficits in spatial cognition, which may contribute to cognitive disorganization, a core symptom of schizophrenia. The purpose of this review is to summarize the known deficits in spatial memory and neural circuits associated with this neuropsychiatric disorder, synthesize key findings, and make recommendations regarding further areas of research needed in the literature. Our review identified several key areas in the brain’s spatial navigation system. First, abnormal hippocampal neuronal responsivity is well-documented in patients with schizophrenia and is associated with impairments in the use of map-based strategies during navigation. Second, alterations in the synchronized firing of neurons in theta frequencies as well as the coupling of theta oscillations across cortical circuits are shown to associate with spatial problem solving. Third, recent research reports that neural representations of space, specifically relating to grid cell function, are abnormal in patients with schizophrenia and are related to deficits in navigation. We suggest that an understanding of the neural bases of behavioral and cognitive symptomology, such as cognitive disorganization, in schizophrenia will benefit from future work advancing integrated theoretical frameworks that include mechanisms of altered hippocampal-parahippocampal neuronal responses including grid cell dysfunction and altered neural oscillation patterns involved in spatial cognition.

Factors associated with medication experience in patients with schizophrenia: a mixed-methods study across three post-discharge time points

BackgroundSchizophrenia requires sustained antipsychotic therapy, yet medication adherence remains suboptimal in over 50% of patients due to suboptimal medication experiences, often leading to self-directed dose reduction or discontinuation. This non-adherence contributes to disease relapse, functional impairment, and substantial familial economic burdens, while recurrent hospitalizations strain healthcare systems. We investigated correlates of medication experiences in patients with schizophrenia using a mixed-methods design with repeated assessments across three post-discharge time points.MethodsOur cohort comprised 425 clinically stable patients with schizophrenia from two tertiary psychiatric hospitals in Heilongjiang Province. Using a mixed-methods design with repeated assessments at three post-discharge time points, we collected concurrent quantitative and qualitative data at three timepoints: pre-discharge (T1), 1-month (T2), and 3-months post-discharge (T3). Quantitative measures included standardized assessments of medication experience (SWN), burden (LMQ), beliefs (BMQ), symptomatology (PANSS), social support (SSRS), and family functioning (APGAR). Machine learning models (logistic regression, random forest, support vector machine) identified key factors associated with medication experience. Qualitative data from 15 patients with suboptimal experiences were analyzed thematically, with mixed-methods integration.ResultsRandom Forest models consistently demonstrated superior predictive performance, identifying the top predictors for each time-point: at T1 – medication beliefs, medication burden and psychotic symptoms (in descending importance); at T2 – medication burden, beliefs, family functioning, and symptoms; at T3 – medication beliefs, social support, burden, symptoms, and family functioning. Qualitative analysis revealed four core themes at T1 and three at T2/T3, showing complementary quantitative-qualitative relationships in benefit-risk perceptions and treatment valuation.ConclusionsThese findings suggest psychiatric nurses may consider interventions that address modifiable factors associated with medication experience: mitigating medication burdens while enhancing perceived treatment benefits during hospitalization (T1); strengthening medication beliefs and family support early post-discharge (T2); and bolstering social support networks during community reintegration (T3). These findings help identify potential intervention targets for future practice to optimize medication experience, and may have implications for medication-related clinical outcomes in patients with schizophrenia.

Brain Quality Control Selectively Eliminates Neurons with Abnormal Variants in Development

By analyzing genomic data from neurons, scientists from Harvard Medical School (HMS), Boston Children’s Hospital, and their collaborators have gained insights into a critical quality-control mechanism that takes place in the developing fetal brain. 

During development, the human brain generates an excess of neurons, most of which are eliminated around when the baby is born. According to a study published this week in Nature, scientists report that neurons with multiple copy number variants, including DNA  duplications or deletions, are widespread in the developing brain. However they are selectively eliminated shortly before or after birth likely because the genomic alterations disrupt their ability to form synapses. 

Full details are provided in a paper titled “Perinatal elimination of genetically aberrant human cortical neuron.” The findings reported there are significant because copy number variants can impact brain function and may contribute to neuropsychiatric conditions, including autism, schizophrenia, epilepsy, and intellectual disability. A better understanding of the pruning process in the developing brain could improve how autism and other disorders in which neural development goes awry are treated. 

As Diane Shao, MD, PhD, HMS instructor of neurology at Boston Children’s and a co-first author on the study noted, “If that quality control system can be disrupted, that could be part of what goes wrong in neurodevelopmental disorders like autism. Understanding the mechanism could eventually point us toward what to look for, and maybe what to protect.”

One of the first steps in the study was exploring the prevalence of copy number variants in developing human brains. To do that, the scientists designed single-cell whole genome sequencing approaches that allowed them to lightly sequence the genomes of single neurons. They used this method to sequence over 1,500 neurons from 16 individuals. They then validated the results with deeper sequencing of over 800 neurons from 12 individuals. They then used various computational methods to identify copy number variants in each sequenced genome. With their approach, it was possible to see the genomic changes “one neuron at a time, map where in the genome they occur, and compare how common they are from before birth to old age,” explained Peter Park, PhD, co-senior author on the paper and professor of biomedical informatics at HMS.

The data showed that an average of nearly 26 percent of neurons in the prenatal cortex had widespread copy number variants, but this rapidly decreased to an average of 6.2 percent after birth. Specifically, “neurons with widespread CNVs were mainly eliminated perinatally, timed roughly parallel to periods of programmed cell death, whereas neurons with smaller CNV burdens declined slowly in frequency with postnatal age,” the scientists wrote.

“We were totally unprepared for how common these were in early development,” said Christopher Walsh, MD, PhD, a co-senior author on the paper and professor of pediatrics and neurology at Boston Children’s Hospital. “But it makes sense in the context of what we know about the formation of excess neurons and in the context of the IVF literature.” 

Next, the team explored the pathways through which the abnormal neurons are eliminated. By sequencing and analyzing DNA and RNA from over 44,000 individual cells, they found that neurons with widespread copy number variants also had abnormal expression of the genes involved in the creation and maintenance of neural synapses. It suggests that unlike healthy brain cells, these abnormal neurons fail to make critical connections during fetal development which causes them to die off. 

“This competition for synapses has been described for years, but without the benefit of a genomic understanding,” Walsh noted. We didn’t realize that this struggle for survival—this Darwinian competition—was nature’s quality control mechanism in the brain.”

As part of the study, the team also confirmed some earlier findings that flawed neurons continue to be eliminated throughout adulthood, albeit at a much slower rate. Currently, they are looking into whether this neural elimination process is different in developing brains of people with autism and other neurodevelopmental disorders. They are also exploring whether this process plays a role in development of adult-onset neurodegenerative disorders like Alzheimer’s disease. 

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Integrated bioinformatics analysis identifies a ubiquitination-related gene signature in schizophrenia with peripheral clinical validation

BackgroundDysregulation of the ubiquitin proteasome pathway is implicated in the pathogenesis of schizophrenia (SCZ). The objective of this study is to identify the dysregulation of the ubiquitin-proteasome pathway and the potential mechanisms associated with SCZ by comprehensive analysis using integrated GEO datasets.MethodsWe integrated three SCZ related datasets containing 1847 ubiquitination-related genes (URGs) from GeneCards and PubMed, addressing batch effects and normalization with R packages. Subsequent Gene Ontology enrichment analysis was applied to the identified URGs, and an 8-gene molecular signature was constructed to distinguish schizophrenia from control brain tissues, and the discriminatory performance was evaluated by the area under the Receiver Operating Characteristic curve. SCZ samples were categorized into high-risk and low-risk groups based on median Risk Scores, followed by gene set enrichment analysis.ResultsA total of 13 SCZ-associated ubiquitin-related differentially expressed genes were significantly identified, with eleven being extremely statistically significant and two highly statistically significant. An 8-gene LASSO-derived molecular signature was constructed and validated, effectively discriminating SCZ patients from controls and classifying SCZ patients into high-risk and low-risk subgroups. The study also constructed protein-protein interaction and regulatory networks and conducted immune infiltration analysis, indicating statistically significant differences in six types of immune cells between the SCZ group and the control group, including CD56bright natural killer cells and central memory CD4+ T cells. ELISA validation in an independent clinical cohort confirmed elevated plasma S100A8 in SCZ patients versus controls, with no significant correlation to PANSS five-factor scores, suggesting S100A8 as a candidate peripheral biomarker reflecting disease state rather than current symptom severity.ConclusionsTogether with the identification of 13 ubiquitination-related DEGs and an eight-gene LASSO signature demonstrating moderate discriminative accuracy for stratifying SCZ patients, this multi-faceted analysis reveals altered ubiquitination patterns in SCZ and provides a hypothesis-generating foundation for future prospective studies incorporating drug-naïve first-episode patients, longitudinal sampling, and appropriate disease controls.

When severe violence becomes a script: a vulnerability-script integration model of media exposure and the form of psychosis-associated maternal filicide

When a publicized act of severe violence is followed by one that resembles it, the resemblance is often read as contagion. This paper argues that resemblance is weak evidence of influence and asks a narrower question: under what conditions can exposure to a publicized crime narrative shape the form of subsequent violence in a person whose antecedent state has already made such violence conceivable? The Vulnerability-Script Integration Model (VSIM) is developed for psychosis-associated maternal filicide. It is an organizing framework with an attached evidentiary protocol and three new propositions: antecedent vulnerability selects exposure as well as moderating its effect; exposure primarily shapes the form rather than the origin of violence; and media influence is inferred only from a dated post-exposure change in narrative-specific behavioral information (acquired or activated) that the documented antecedent state does not parsimoniously explain. The model specifies five functional stages, two moderators, a clinically defined and non-circular vulnerability construct, discriminant coding rules, a causal diagram with explicit estimands, and six predictions with stated classification, test, disconfirming, and inconclusive evidence. A closed, adjudicated case in which a court-tested claim of media scripting proved false illustrates the evidentiary rules. Clinical and reporting implications are framed as research questions.