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Homocysteine, Methylenetetrahydrofolate Reductase and Risk of Schizophrenia

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Homocysteine, Methylenetetrahydrofolate Reductase and Risk of Schizophrenia Molecular Psychiatry (2006) 11, 143–149 & 2006 Nature Publishing Group All rights reserved 1359-4184/06 $30.00 www.nature.com/mp ORIGINAL ARTICLE Homocysteine, methylenetetrahydrofolate reductase and risk of schizophrenia: a meta-analysis JW Muntjewerff1, RS Kahn2, HJ Blom3 and M den Heijer4 1GGz Nijmegen, Mental Health Institute Nijmegen, Nijmegen, The Netherlands; 2Department of Psychiatry, University Medical Center Utrecht, Utrecht, The Netherlands; 3Laboratory of Paediatrics and Neurology, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands and 4Department of Endocrinology and Epidemiology and Biostatistics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Elevated plasma homocysteine concentration has been suggested as a risk factor for schizophrenia, but the results of epidemiological studies have been inconsistent. The most extensively studied genetic variant in the homocysteine metabolism is the 677C4T polymorphism in the methylenetetrahydrofolate reductase (MTHFR) gene, resulting in reduced enzyme activity and, subsequently, in elevated homocysteine. A meta-analysis of eight retrospective studies (812 cases and 2113 control subjects) was carried out to examine the association between homocysteine and schizophrenia. In addition, a meta-analysis of 10 studies (2265 cases and 2721 control subjects) on the homozygous (TT) genotype of the MTHFR 677C4T polymorphism was carried out to assess if this association is causal. A 5 lmol/l higher homocysteine level was associated with a 70% (95% confidence interval, CI: 27– 129) higher risk of schizophrenia. The TT genotype was associated with a 36% (95% CI: 7–72) higher risk of schizophrenia compared to the CC genotype. The performed meta-analyses showed no evidence of publication bias or excessive influence attributable to any given study. In conclusion, our study provides evidence for an association of homocysteine with schizophrenia. The elevated risk of schizophrenia associated with the homozygous genotype of the MTHFR 677C4T polymorphism provides support for causality between a disturbed homocysteine metabolism and risk of schizophrenia. Molecular Psychiatry (2006) 11, 143–149. doi:10.1038/sj.mp.4001746; published online 20 September 2005 Keywords: folate; genetics; homocysteine; methylenetetrahydrofolate reductase; psychiatric disorder; neurodevelopment; schizophrenia Introduction of schizophrenia. Evolving from the original trans- methylation hypothesis postulating that an abnor- It is commonly accepted that both genetic and mally (toxic) methylated metabolite might be the environmental factors contribute to the aetiology cause of schizophrenia,6 it was suggested subse- and clinical phenotype of schizophrenia. Despite quently that disturbances in the single-carbon meta- numerous family, twin, and adoption studies in bolism itself might be causative.7 Methylation which evidence for hereditary and environmental processes are vital for normal cell functioning contributions to schizophrenia is presented,1–4 no because of their key role in protein, lipid and DNA underlying inherited mechanism has yet been identi- metabolism, gene expression, synthesis of neurotrans- fied. Although several putative susceptibility genes mitters and detoxification processes.8 Initial clinical for schizophrenia have been identified,5 the patho- evidence for an impaired methyl-carbon pathway in genic mechanisms remain to be resolved. Evidence of schizophrenic patients stems from many methionine an association between schizophrenia and a specific administration studies ranging from the 1960s until aberrant metabolism could reveal new candidate the early 1990s. These studies showed that treatment genes and might provide more insight in the complex with high-daily doses of L-methionine resulted in aetiology of schizophrenia. exacerbation of schizophrenic symptoms.9,10 In addi- Dysfunctional single-carbon transfer reactions in- tion, as compared to controls the rate of whole body volving the methionine–homocysteine metabolism methylation was found to be decreased in patients have been proposed to be relevant in the aetiology with schizophrenia.11,12 It was suggested that these findings might reflect an enzymatic defect or a failure Correspondence: Dr JW Muntjewerff, GGz Nijmegen, Mental of a control mechanism of the single-carbon cycle Health Institute Nijmegen, PO Box 7049, 6503 GM Nijmegen, in schizophrenic patients.13 The finding of a defect The Netherlands; E-mail: [email protected] in methylation due to severe dysfunction of 5,10- Received 17 December 2004; revised 6 July 2005; accepted 9 methylenetetrahydrofolate reductase (MTHFR) result- August 2005; published online 20 September 2005 ing in hyperhomocysteinemia in a subject with Homocysteine metabolism and schizophrenia: a meta-analysis JW Muntjewerff et al 144 schizophrenia-like symptoms14 was therefore of great phrenia for cases, (b) use of a case–control design and interest. Homocysteine is a sulphur containing ami- (c) publication in an English-language, peer-reviewed, no-acid derived from the demethylation of the indexed scientific journal. Meeting abstracts were not essential amino-acid methionine, which is the only allowed. We also included our recent published dietary precursor of homocysteine. The metabolism of data.22 homocysteine depends on several B-vitamins includ- ing folate, cobalamin, pyridoxine and riboflavin. Data extraction and synthesis MTHFR is the essential enzyme in the folate- For the meta-analysis of homocysteine and schizo- mediated single-carbon transfer reactions. A common phrenia, information was extracted from each study polymorphism exists in the catalytic domain of the on: the odds ratio (OR) and 95% confidence interval MTHFR enzyme. The gene is localized on chromo- (CI) as a risk estimate for the association between some 1p36.3,15 in which a C4T substitution at elevated homocysteine and schizophrenia and the position 677 results in a substitution of alanine to number of cases and controls. If the OR and 95% CI valine.16 The reported prevalence of the homozygous were not provided, they were calculated from the 677C4T (TT) genotype is between 0 and 32% of the number of cases and controls above and below a population world-wide,17 ranging from 5 to 15% in particular homocysteine concentration as a cutoff Caucasian populations.18 The single amino-acid sub- point from the control distribution in each study stitution results in impaired flavin adenine dinucleo- using Woolf’s method.23 The homocysteine studies tide (FAD) binding, leading to loss of folate resulting, included in our meta-analysis reported different in its turn, in reduced activity of MTHFR.19 Subjects definitions of hyperhomocysteinemia by using differ- with the TT genotype have about 25% higher ent cutoff levels. Most studies provided the 90th homocysteine levels than those with the normal percentile of homocysteine levels in the control homozygous (CC) genotype,18 whereby the impact of group, while other studies reported the 95th or 75th the polymorphism varies according to folate or percentile. For pooling of risk estimates, it is essential riboflavin status.20,21 that these estimates are based on a single unit of Elucidation of an association between a genetic comparison. Previous studies on homocysteine and variant associated with elevated homocysteine levels homocysteine-related diseases reported linear dose– and schizophrenia might be informative about the effects relations.24–26 In line with these findings, we hypothesis that higher levels of homocysteine play a calculated the OR for a 5 mmol/l increase in homo- causal role in the aetiology of schizophrenia. Indivi- cysteine level, a standard reference increment. To dual case–control studies concerning homocysteine estimate the log OR for a 5 mmol/l increase in or the 677C4T polymorphism included too few cases homocysteine, information about the normal distribu- and controls to produce reliable evidence for an tion was used to calculate the expected mean level of association with schizophrenia. homocysteine in the groups being compared. For The aim of this study was to examine the associa- example, the mean value in the top fifth of a normal tion between homocysteine and schizophrenia by distribution is 1.4 standard deviation (s.d.) above the conducting a meta-analysis of case–control studies on mean, and the mean in the bottom fifth is 1.4 s.d. this topic. In order to assess whether such association below the mean. Hence, the OR comparing the top to is causal, we have also performed a meta-analysis of the bottom fifth is also the OR for a 2.8 s.d. difference all case–control observational studies with available in homocysteine levels. Wherever possible, the s.d. in data on the MTHFR 677C4T polymorphism and controls was used to estimate the difference in mmol/l schizophrenia. between the top and bottom fifth of a study, but if this was not reported, then a weighted average was used of the s.d. from the studies that did report Method it. Assuming the association was log–linear, it was Study identification then possible to calculate the OR for a unit change Eligible studies were identified by searching the in homocysteine and hence for a 5 mmol/l increase in electronic NLM MEDLINE database for relevant homocysteine. reports published up to and including December For the meta-analysis of the MTHFR 677C4T 2004 using the search terms (‘homocysteine’ or polymorphism and schizophrenia, data were col- ‘hyperhomocysteinemia’ or ‘MTHFR’) and (‘schizo-
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