Biomarkers of Conversion Risk and Treatment Response in Early-Stage Schizophrenia

Study Overview
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Brief Summary
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Schizophrenia (SZ) is a highly debilitating neuropsychiatric disorder of young adulthood onset and a leading cause of disability worldwide. While treatments delivered at early stages of the disorder may be effective at reducing psychosis or altering the course of the disease, there are currently no biomarkers capable of identifying subjects in early stages of SZ who are likely to respond to treatment and would be good candidates for available proactive, symptomatic or future disease-modifying treatments; or those who would not respond and can be spared unnecessary medication exposure. The lack of these vitally important biomarkers provides a compelling rationale for the present multidisciplinary research project, which aims to develop and validate highly promising noninvasive and objective proton magnetic resonance spectroscopy (1H MRS)-based biomarkers for monitoring treatment response in early stages of SZ. In support of the viability of this overall objective is a large body of data, reported by the applicants and others, that show (a) that levels of glutamate (Glu) and - aminobutyric acid (GABA) - respectively, the major excitatory and inhibitory amino acid neurotransmitter systems - are abnormally elevated in medication-naïve and unmedicated first episode and chronic SZ patients; (b) that the effect of treatment with antipsychotic medications in these populations may be to lower or normalize brain levels of both Glu and GABA. To investigate the potential of these in vivo brain Glu and GABA abnormalities to serve as biomarkers of treatment response in early-stage SZ, the applicants propose to use 1H MRS to measure Glu and GABA levels in the largest cohort of medication-free SZ subjects to date, at baseline and following 4 weeks of antipsychotic treatment.

Official Title
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Biomarkers of Conversion Risk and Treatment Response in Early-Stage Schizophrenia

Conditions
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Schizophrenia Spectrum and Other Psychotic Disorders

Intervention / Treatment
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* Drug: Risperidone


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria (Patients): Male or females between the ages of 18-35 less than five years (<60 months) of active Diagnostic and Statistical Manual of Mental Disorders (DSM) diagnosis of schizophrenia, schizophreniform, or schizoaffective disorder Capacity to provide informed consent No major medical or neurological illness Medication free (3 weeks without antipsychotic medications) Exclusion Criteria (Patients): Current alcohol or drug abuse (<1 month) or substance dependence (<6 months) or substances used within one day of the imaging study. Pregnant or lactating women or women of child-bearing potential, who are either not surgically-sterile or, for outpatients, not using appropriate methods of birth control. Intelligence Quotient (IQ) <70 Acute risk for suicide or violence Presence of pacemaker or any metallic objects in the body that would interfere with the MRS or cause MRI safety problems Claustrophobia Any organic brain disorder (including epilepsy, mental retardation, or a medical condition whose pathology or treatment would likely alter the presentation or treatment of SZ Individuals on anti-epileptic medications (e.g., valproate, carbamazepine) that may affect GABA or Glu Unstable medical or neurological condition DSM-V diagnosis of bipolar disorder I DSM-V diagnosis of major depression with psychotic features History of non-response to or non-tolerance of Risperidone Inclusion Criteria (Healthy Controls) Male or females between the ages of 18-35 less than five years (<60 months) of active DSM diagnosis of schizophrenia, schizophreniform, or schizoaffective disorder No major medical or neurological illness Exclusion Criteria (Healthy Controls) Current alcohol or drug abuse (<1 month) or substance dependence (<6 months) or substances used within one day of the imaging study. Pregnant or lactating women or women of child-bearing potential, who are either not surgically-sterile or, for outpatients, not using appropriate methods of birth control. IQ<70 Acute risk for suicide or violence Presence of pacemaker or any metallic objects in the body that would interfere with the MRS or cause MRI safety problems Claustrophobia History of psychotropic medication use such as antipsychotics or antidepressants Any first-degree family history of psychotic illness Personal history of any DSM Axis I disorder Individuals on anti-epileptic medications (e.g., valproate, carbamazepine) that may affect GABA or Glu Unstable medical or neurological condition Any organic brain disorder (including epilepsy, mental retardation, or a medical condition whose pathology or treatment would likely alter the presentation or treatment of SZ

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 35 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Basic Science
Allocation: Non-Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Patient<br>Medication-free individuals during first-episode of psychosis who will receive 4 weeks of treatment with risperidone | Drug: Risperidone<br>* Participants will meet with a study doctor physician once per week (about 3 times total) to monitor progress and side-effects of risperidone, which includes taking 4 assessments each time. After 4 weeks of taking Risperidone, participant will be assessed and scanned with the MRI/MRS scanner again.<br>|
| No Intervention: Control<br>Healthy, psychosis-free controls who will not receive risperidone | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in biomarkers of treatment response: Dorsal Caudate (DCA) GABA levels | Dorsal Caudate (DCA) GABA levels will be ascertained at baseline and after 4 weeks of treatment using MRI scan with 1H MRS to assess treatment response. | Baseline and 4 weeks of treatment | 
| Change in biomarkers of treatment response: Dorsal Caudate (DCA) Glutamate | Dorsal Caudate (DCA) Glutamate levels will be ascertained at baseline and after 4 weeks of treatment using MRI scan with 1H MRS to assess treatment response. | Baseline and 4th week of treatment | 
| Change in biomarkers reflecting treatment response: Medial Prefrontal Cortex (MPFC) GABA | Medial Prefrontal Cortex (MPFC) GABA levels will be ascertained at baseline and after 4 weeks of treatment using MRI scan with 1H MRS to assess treatment response. | Baseline and 4th week of treatment | 
| Change in biomarkers reflecting treatment response: Medial Prefrontal Cortex (MPFC) Glutamate | Medial Prefrontal Cortex (MPFC) Glutamate levels will be ascertained at baseline and after 4 weeks of treatment using MRI scan with 1H MRS to assess treatment response. | Baseline and 4th week of treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Changes in neurocognitive performance: MATRICS Consensus Cognitive Battery (MCCB) | Memory, attention, reasoning, emotional intelligence, and verbal ability will be assessed using the MCCB before and after 4 weeks of treatment. | Baseline and 4th week of of treatment | 
| Changes in everyday functioning: University of California San Diego (UCSD) Performance-based Skills Assessment (UPSA) | Ability to function in a variety of everyday tasks from six domains (Financial Skills, Communication, Comprehension/Planning, Transportation, Household Management and Medication Management) will be assessed using the University of California San Diego Performance-based Skills Assessment (UPSA) before and after 4 weeks of treatment. | Baseline and 4th week of treatment | 
| Changes in clinical symptomatology: Positive and Negative Syndrome Scale (PANSS) | Changes in Positive and Negative Symptoms will be assessed across the treatment period using the PANSS. Participants are rated on a scale of (Absent) (Minimal) (Mild) (Moderate) (Moderate severe) (Severe) (Extreme) to describe Positive, Negative and General symptomatology. Items from each subscale (Positive, Negative, and General) are summed for their respective scales, with lower numbers indicating less severe or absent symptomatology, and higher scores indicating more severe symptoms. A total sum of all subscales is also computed to reflect overall symptom severity. Positive Subscale: 7 items, minimum score = 7, maximum score = 49 Negative Subscale: 7 items, minimum score = 7, maximum score = 49 General Subscale: '16 items, minimum score = 16, maximum score = 112 Total Score: 30 items, minimum score = 30, maximum score = 210. | Treatment week 1, treatment week 2, treatment week 3 | 
| Changes in motor symptomatology: Abnormal Involuntary Movement Scale (AIMS) | Changes in motor symptomatology associated with tardive dyskinesia (TD) assessed using the Abnormal Involuntary Movement Scale (AIMS). The measure consists of 14 items with scale 0 None Minimal Mild Moderate Severe Higher ratings -> higher levels of motor symptoms. Items 1-7 assess abnormal movements for parts of the body. Ratings are summed to produce a score of total motor symptomatology (min 0, max 28). Item 8 = rating of overall symptom severity based on observation, using the same scale as above. Item 9 = rating of the incapacity of the subject due to abnormal movements, using the same scale as above. Item 10 = rating of the level of awareness and distress in the participant over the abnormal movements, with 0 =No Awareness = Aware, no distress =  , mild   =  , moderate   =  , severe   Item 11-13 = yes/no, rule out dental problems that can lead to a mistaken diagnosis of TD. Item 14 = yes/no if symptoms disappear or persist during sleep. | Treatment week 1, treatment week 2, treatment week 3 | 
| Changes in clinical severity: Clinical Global Impression Scale | Changes in clinical severity over the course of treatment will be monitored using the The Clinical Global Impression Scale (CGI) consists of two items.- Severity scale (CGI-S). Severity - The first item assesses the patient's current level of mental health symptomatology compared to the clinician's experience with other patients with the same diagnosis. The scale ranges from (Normal, not at all ill) (Borderline mentally ill) (Mildly ill) (Moderately ill) (Markedly ill) (Severely ill) (Among the most extremely ill patients) Improvement - The second item assesses how much the patient's symptomatology has changed since the last clinical visit. Very much improved Much improved Minimally improved No change Minimally worse Much worse Very much worse | treatment week 1, treatment week 2, treatment week 3 | 
| Changes in global functioning: Global Assessment of Functioning (GAF) | Changes in global functioning over the course of treatment will be assessed using the Global Assessment of Functioning (GAF). Participants are rated 1-100 on their level of functioning, according to clinical observation: 91 - 100 No symptoms. 81 - 90 Absent or minimal symptoms 71 - 80 If symptoms are present, they expected reactions to stressors 61 - 70 Some mild symptoms 51 - 60 Moderate symptoms 41 - 50 Serious symptoms 31 - 40 Impairment in reality testing or communication or major impairment in several areas 21-30 Behavior influenced by delusions or hallucinations or serious impairment in communication/judgment/inability to function in almost all areas 11-20 Some danger of hurting self or others or occasionally fails to maintain minimal personal hygiene or gross impairment in communication 1-10 Persistent violence risk or lack of self-care 0 No info | Treatment week 1, treatment week 2, treatment week 3 | 
| Recreational Substances Used by Patients as Recorded by the Substance Use Questionnaire | This measure is a self-reported questionnaire which assesses for any use of the following substances within the past month prior to the initial research visit Tobacco (if the respondent indicates that they have used tobacco in the past month, they are additionally asked, On average, how many cigarettes per day have you smoked in the past 7 days? Alcohol, Cocaine, Marijuana, Opiates, Amphetamines, PCP Other Drugs of Abuse (if the respondent indicates they have used other drugs of abuse within the past month of the initial research visit, they are given the opportunity to specify which other drugs of abuse they used | This measure is administered on Day 1 of the study. | 
| Participants' Verbal I.Q as Assessed by the WTAR to Determine Clinical Eligibility | This measure assesses a participant's verbal ability to determine whether they are cognitively able to complete the measures involved in the study. The participant will read from a list of 50 English words and the rater will record whether the pronunciation was correct on a score card for each word spoken. A standard score below the 70th percentile on this measure is indicative of an intellectual disability which would exclude a participant from being clinically and cognitively eligible to complete this study. | This measure is completed on Day 1 of the study. | 
| Participants' Self-Reported Handedness as Recorded by the Edinburgh Handedness Scale | This measure assesses a participant's preference regarding which hand they would use to complete a specific task. They have the option to indicate whether they would use they would always or most of the time use their left, right, or both left and right hands to complete each task. This measure assesses handedness based on the amount of responses which indicate the participant is either left handed, right handed, or ambidextrous. | This measure is completed on Day 1 of the study. |