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Cannabis and Psychosis … Genetics Continuum … Neurogenesis and Schizophrenia … Treatment-Refractory Schizophrenia … Stigma …

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Cannabis and Psychosis … Genetics Continuum … Neurogenesis and Schizophrenia … Treatment-Refractory Schizophrenia … Stigma … Clinical News … putative antipsychotics … bipolar disorder and schizophrenia … cannabis and psychosis … genetics continuum … neurogenesis and schizophrenia … treatment-refractory schizophrenia … stigma … Peter F. Buckley, MD Editor-in-Chief Update on Putative Antipsychotics Risperidone is an established antipsychotic medica- We have previously described the pharmacology and tion, available now in various formulations. The latest development of MIN-101, a putative antipsychotic (now formulation of Risperidone as a long-acting injectable is bearing the name Roluperidone) without dopamine receptor an oral monthly drug (known as PERSERIS) delivered by binding while with marked affinity for serotonin 5-HT2A subcutaneous route. This formulation was developed by the and sigma-2 receptors. Results of a 12-week study of Ro- biopharmaceutical company Indivior. This formulation has luperidone for cognitive dysfunction in schizophrenia are been approved by the U.S. Food and Drug Administration now available online (see Journal of Clinical Psychiatry, based upon Phase 3 clinical trials in patients with schizo- online) and show a modest benefit in verbal fluency measure phrenia. in patients receiving 32 mg of Roluperidone. This drug is Autism Spectrum Disorder and under development through the clinical trials program of the biopharmaceutical company Minerva Neuroscience Inc. Maternal Nutritional Health: Intra-Cellular Therapies Inc. (ITCI) is developing a Implications of Schizophrenia putative antipsychotic, Lumateperone (ITI-007), which is a It is estimated that 1 in 5 mothers of offspring who later neuromodulator of dopamine (as a phosphoprotein modula- develop schizophrenia have experienced an obstetric com- tor, with presynaptic partial agonism and postsynaptic an- plication during that pregnancy. Moreover, low folic acid tagonism at D2 receptors), serotonin, and glutamate recep- and vitamin D deficiency in utero have been proposed as tors. ITCI is developing this agent as a potential treatment risk factors for schizophrenia. Given that context, the recent for several neuropsychiatric conditions beyond schizophre- case-controlled Israeli short study of some 45,000 children nia. Three studies in schizophrenia suggest efficacy and fa- by Levine and colleagues (2018) is noteworthy and illustra- vorable tolerability of Lumateperone. tive. Maternal nutritional health with adequate folic acid and Brexpiprazole, approved for the treatment of schizo- multivitamin supplementation were associated with a lower phrenia and an adjunctive treatment for major depression, is risk of later expression of autism spectrum disorder. This also being considered in clinical trials as a potential agent to is an important observation with substantial public health treatment agitation in patients with Alzheimer’s disease. A implications. 12-week clinical trial is now underway. Levine SZ, Kodesh A, Viktorin A, Smith L, Uher R, Reichenberg A, et al. Neurocrine Biosciences has developed Valbenazine Association of maternal use of folic acid and multivitamin supplements in (known as Ingrezza) in the U.S. for the treatment of tardive the periods before and during pregnancy with the risk of autism spectrum dyskinesia. The biopharmaceutical company has also devel- disorder in offspring. JAMA Psychiatry 2018;75(2):176-184. oped another agent Opicapone (known in Europe as Ongen- tys), which is available in Europe for the treatment of Par- Bipolar Disorder and Schizophrenia: kinson’s disease. It is noteworthy to observe this resurgence Coming Together or Coming Apart? of drug development in movement disorders, as well as in Among a remarkable array of genetic experts in seri- their neuropsychiatric manifestations, including psychosis. ous mental illness, Ruderfer and colleagues (2018) utilized Clinical Schizophrenia & Related Psychoses Fall 2018 • 101 Clinical News a pooled database of some 54,000 patients in a case con- Neurogenesis and Schizophrenia trol design of the genetic interface between schizophrenia Earlier basic science studies raised optimism that and bipolar disorder. Some 114 loci were highlighted in this ingesting antipsychotic drugs—and lithium for bipolar dis- large genome-wide association study (GWAS), with several orders and antidepressants for depression—stimulates new points of convergence and with more distinct portfolio for cell growth. Liu and Howard review the literature and ex- bipolar disorder with psychotic features. This study is in- press optimism for future treatments, albeit as they add it triguing because it simultaneously upholds the proposition is difficult to demonstrate directly that neurogenesis has/is of a shared genetic profile between schizophrenia and bipo- occurring. lar disorder, as well as a distinction of genetic contribution Liu KY, Howard R. Why has adult hippocampal neurogenesis had so little across these conditions. impact on psychiatry? Br J Psychiatry 2018;212(4):193-194. Ruderfer D, Ripke S, McQuillin A, Boocock J, Stahl EA, Pavlides JMW, et al. Genomic dissection of bipolar disorder and schizophrenia, including 28 Cannabis Use: A Gateway to Later subphenotypes. Cell 2018;173(7):1705-1715. Opioid Use and Psychosis Risk? Convergent lines of evidence point to a higher rate of Genetic Associations for Major later psychosis among cannabis users. To some extent, this Depressive Disorder: Implications point has been lost politically since both medical marijuana for Schizophrenia and general cannabis use has become increasingly legalized Howard and colleagues (2018) report 17 independent across the U. S. A recent report by Olfson and colleagues loci that were identified in a large (300,000 plus) genome- (2018) adds to another dimension to this consideration, wide association study (GWAS) of depression from a British namely the relationship between cannabis use and later sample that includes broad and more constructed definitions opioid addiction. In the National Epidemiologic Survey of depression. Interestingly with respect to schizophrenia of Alcohol and Related Conditions (NESARC), three-year research, there is a marked similarity (to the untrained eye) prospective longitudinal assessments show higher rates between the Manhattan plot of this large GWAS in depres- of opioid use (observed: expected rate of 5. 87 at year one) sion and the 108 loci Manhattan plot reported for schizo- among those with cannabis use, especially so among those , phrenia. Also noteworthy were the genetic correlations be- with pain difficulties (observed: expected rate of 2.99). A tween depression and schizophrenia, depression and bipolar very compelling report. disorder, as well as depression and attention deficit hyperac- tivity disorder. In contrast, there were no relationships iden- Olfson M, Wall MM, Liu SM, Blanco C. Cannabis use and risk of pre- scription opioid use disorder in the United States. Am J Psychiatry tified between depression and autism spectrum disorder. 2018;175(1):47-53. Howard DM, Adams MJ, Shirali M, Clarke TK, Marioni RE, Davies G, et Predictive Association Between al. Genome-wide association study of depression phenotypes in UK Bio- bank identifies variants in excitatory synaptic pathways. Nat Commun Adolescent Cannabis Use and 2018;9(1):1470. Subsequent Psychosis Genes and Birth: Additive Bed Fellows The Northern Finland Birth Cohort of 1986 was used Ursini and colleagues (2018) from the Lieber Institute to track cannabis use, prodromal symptoms, and the emer- report an overall 12-fold increased risk of schizophrenia gence of florid psychosis in a large sample (over 7,300) among 5 genetic samples. The identified genes are related to initially evaluated at age 15–16 years and followed up to placental function and are highly expressed in placenta from age 30 years. There was a powerful effect on cannabis use individuals that come from pregnancies with birth compli- increasing the risk of psychosis by 6.5 times. This robust cations. This is an interesting and provocative finding that effect remained even with potential confounds of prodromal reminds us of the synergistic effect of individual risk factors features (timing effect), parental psychosis (genetic effect), or other substance abuse (illicit drug effect). This is yet an- for schizophrenia. other confirmatory study of the risk of psychosis among in- Ursini G, Punzi G, Chen Q, Marenco S, Robinson JF, Porcelli A, et al. Con- dividuals who use/misuse cannabis. Interestingly, there was vergence of placenta biology and genetic risk for schizophrenia. Nat Med a “dose response” effect between the extent of cannabis use 2018;24(6):792-801. and occurrence of psychosis. 102 • Clinical Schizophrenia & Related Psychoses Fall 2018 Peter F. Buckley, MD Mustonen A, Niemela S, Nordstrom T, Murray GK, Maki P, Jaaskelainen E, effects of cannabidiol (CBD) on cognition and symptoms in outpatients et al. Adolescent cannabis use, baseline prodromal symptoms and the risk with chronic schizophrenia: a randomized placebo controlled trial. Psycho- of psychosis. Br J Psychiatry 2018;212(4):227-233. pharmacology (Berl) 2018;235(7):1923-1932. Cannabis and Psychosis Treatment-Resistant Depression: Colizzi and Murray (2018) make a passionate plea Definition, Detailing, and Implications for thoughtful deliberation on public policies on cannabis for Refractory Schizophrenia concerning emergent use of cannabidiol which may have Anderson (2018) provides a thoughtful, clinically non-addictive—as well as healing—properties. This ar- oriented review of the nosology of treatment-resistant ticle also nicely
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