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  • ALTERING THE COURSE OF SCHIZOPHRENIA: CHALLENGES AND OPPORTUNITIES

    Mark J. Millan

    Neuropsychiatry Department Institut de Recherches Servier

    Croissy-sur-Seine (Paris), France

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 1

  • 5/1/2015 6:11 AM Suzdal, 21 April, 2015 2

    SCHIZOPHRENIA AND ITS IMPACT: CORE ELEMENTS AND OVERVIEW OF TALK

    • Severe, chronic and debilitating disorder with early onset (18-30), reduced life-expectancy and a high incidence of suicide (~10 %). • Prevalence about 1% of the population with little geographical/cultural variation.

    • Huge economic burden - inability to work, social support and hospitalisation. Cost is nearly 100 billion Euros per year for the EU (Wittchen et al, 2011). • Clinically heterogeneous with a complex pattern of emotional, social and cognitive symptoms: incompletely understood causes and pathophysiology, but much recent progress. • Symptomatic treatment of limited efficacy: neuroleptics (haloperidol…), clozapine, second-generation antipsychotics (risperidone…) and aripiprazole.

    This presentation discusses:

    - The new concept of course- alteration, preventing and stopping the progress of schizophrenia: key questions - whom to treat, when to treat, how to treat. - Clinical and experimental data supporting course-alteration, and broader implications of the concept.

  • 5/1/2015 6:11 AM Suzdal, 21 April, 2015 3

    Co-morbid: Depression Anxiety…

    Cognitive Symptoms (1980s/1990s) Attention, Working memory Executive function (planning)

    Speed of processing

    Impaired Social Cognition* (2000+) Use of social cues to assess emotions,

    intentions and mental states of others - and to guide ones own behaviour

    *Eye contact, gaze, facial expression, gestures…

    Emil Kraeplin (1890’s)* Eugen Bleuler (1910’s) SCHIZOPHRENIA: “BORN” IN GERMANY

    Positive Symptoms Delusions (false beliefs - persecution,

    great powers) Hallucinations (visual, auditory -

    hearing orders) Disorganisation: Thought, Speech,

    Behaviour

    Negative Symptoms ↓Motivation,

    ↓Sociality, ↓Expression

    (verbal and non-verbal)

    « Organic disorder »

    « Psychological dimension »

    * « Dementia Praecox »

  • MOUNTAIN GORILLAS: SOCIAL COGNITION IN ACTION

    Subordinate male and female “interacting” and looking nervous : WHAT’S GOING ON ? AND WHAT HAPPENED NEXT ?

    Photo from RW Byrne Aberdeen, 2007 5/1/2015 6:11 AM Suzdal, 21 April, 2015 ,,4

  • IMPAIRED SOCIAL COGNITION MAY DRIVE OTHER SYMPTOMS OF SCHIZOPHRENIA

    Deficits in other cognitive domains

    Paranoia Suspiciousness

    Delusions False beliefs

    ↓ Social Motivation

    ↓ Social Interaction

    Leading to: False attribution of

    Intentions and anomalous social behaviour

    Misinterpreting /Ignoring social cues: Defective

    social processing

    Impaired Social

    Cognition

    Co-morbid Anxiety/Depression

    Positive Symptoms

    Negative Symptoms

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 5

  • Adolescence

    Crises

    Min

    Max

    Sy m

    pt om

    In te

    ns ity

    Diagnosis

    Birth

    Infection, Trauma, Malnutrition

    Hypoxia

    10 15 20 25 Years 0 5 -1 30 35 40 45

    Social isolation, Drug abuse,

    « Stress »

    Pregnancy

    Genetic Load

    CORE CHARACTERISTICS, CUMULATIVE CAUSES AND CHRONIC COURSE OF SCHIZOPHRENIA

    Urban-rearing, Migration

    Childhood Adulthood

    Relapse/Remission

    D ia

    gn os

    tic

    Su b-

    th re

    sh ol

    d

    1st Wave hits "Booster" hits 2nd Wave hits

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 6

    Infancy

    First Episode

    Disorganisation. Positive, negative, cognitive

    symptoms. Impaired social cognition/processing.

    Mood disruption.

  • Adolescence

    Crises

    Min

    Max

    Sy m

    pt om

    In te

    ns ity

    Diagnosis

    Birth

    Infection, Trauma, Malnutrition

    Hypoxia

    10 15 20 25 Years 0 5 -1 30 35 40 45

    Social isolation, Drug abuse,

    « Stress »

    Pregnancy

    Genetic Load

    CHARACTERISTICS, CAUSES, COURSE AND CONTROL OF SCHIZOPHRENIA TODAY

    Urban-rearing, Migration

    Childhood Adulthood

    Relapse/Remission

    D ia

    gn os

    tic

    Su b-

    th re

    sh ol

    d

    *Symptomatic treatment: mainly positive!

    1st Wave hits "Booster" hits 2nd Wave hits

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 7

    Infancy

    Coping/Self-help

    First Episode

    Disorganisation. Positive*, negative, cognitive

    symptoms. Impaired social cognition/processing.

    Mood disruption.

  • Enhance efficacy vs positive symptoms

    Better control negative

    symptoms

    Improve tolerance

    Chlorpromazine, haloperidol - neuroleptics (1952 on): Only positive symptoms, motor side-effects

    Clozapine (1989): still Gold Standard for efficacy !! - but safety issues and not cog/social nor negative.

    Second-generation agents (1994 on), risperidone, aripiprazole… not more efficacious.

    Reduce cognitive/social

    impairment

    ↓ Resistance / ↑ Remission

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 8

    IMPROVING EFFICACY OF SYMPTOMATIC TREATMENT OF SCHIZOPHRENIA LITTLE SUCCESS DURING 60 YEARS !

    Modest progress

  • • Precedents from other domains - “Disease-modification” - Statins for reducing excess cholesterol and risk of cardiovascular disorders. - Attempts to block beta-amyloid and progression of Alzheimer’s disease. - Rescuing functional (GABA) deficits in autism-related disorders like Down Syndrome. • Recent emergence for schizophrenia - “Course-alteration” - Rethinking schizophrenia Tom Insel (Director of National Inst. Mental Health, US), Nature 2010

    - A new beginning for a broken mind: reversing synaptic dysfunction Marin and Rico, Neuron, 2013 - Prediction and prevention of psychosis in youth at clinical high-risk

    Stafford MR et al (National Health Service, UK), Br Medical Journal, 2013

    FROM SYMPTOMATIC TREATMENT TO COURSE-ALTERATION FOR SCHIZOPHRENIA: A NEW WAY OF THINKING

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 9

  • 5/1/2015 6:11 AM Suzdal, 21 April, 2015 10

    DISEASE-MODIFICATION AND COURSE-ALTERATION: GENERAL CONSIDERATIONS

    Course-alteration

    *Durably and directly impact core pathophysiological

    processes causing schizophrenia.

    Counter aggravating mechanisms.

    Promote counter-regulatory mechanisms opposing disease progression.

    Prevention: ↓ Conversion in clinically

    high-risk subjects.

    Rescue: ↓ Progression/reversal following diagnosis.

    Biomarkers: Readouts of pathophysiological processes

    *Disease-modification

  • COURSE-ALTERATION AS A POTENTIAL PARADIGM SHIFT FOR SCHIZOPHRENIA:

    THREE CRUCIAL AND INTERRELATED ISSUES

    WHEN TO TREAT ?

    WHOM TO TREAT ?

    HOW TO TREAT ?

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 11

  • COURSE-ALTERATION AS A POTENTIAL PARADIGM SHIFT FOR SCHIZOPHRENIA :

    WHEN TO TREAT ?

    AT WHAT PHASE OF THE DISORDER RELATIVE TO DIAGNOSIS ?

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 12

  • 5/1/2015 13

    Min

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    10 15 20 25 Years 0 5 -1 30 35 40 45

    COURSE-ALTERATION FOR SCHIZOPHRENIA: WHEN TO TREAT ?

    High-Risk subjects First episode Chronic, fluctuating Pre-morbid

    «Prevent-Protect» «Rescue-Restore»

    D ia

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    Su b-

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    Risky: Impossible to show?

    Too late: Irreversible changes?

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 13

    WINDOW OF OPPORTUNITY

    Course-alteration

    Brain Formation

    Brain Re-organisation

    Brain Upkeep

    Schizophrenia Diagnosis

    Decrease transition and impede progression

  • COURSE-ALTERATION AS A POTENTIAL PARADIGM SHIFT FOR SCHIZOPHRENIA :

    WHOM TO TREAT ? I

    HOW TO IDENTIFY PEOPLE AT HIGH RISK ?

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 14

  • Min

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    10 15 20 25 Years 0 5 -1 30 35 40 45

    Di ag

    no st

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    COURSE-ALTERATION FOR SCHIZOPHRENIA: PEOPLE AT HIGH RISK SHOW MODEST SYMPTOMS PRIOR TO DIAGNOSIS

    5/1/2015 6:11 AM Suzdal, 21 April, 2015 15

    Disorganisation. Positive, negative, cognitive

    symptoms. Impaired social cognition/processing

    Mood