29RESEARCH
Telomere Length as a Marker of Suicidal Risk in Schizophrenia
BACKGROUND: Schizophrenia and suicidal behavior are associated with shortening in the length of telomeres. The aim of the study was to compare the content (pg/mcg) of telomeric repeat in DNA isolated from peripheral blood cells in three groups of subjects: patients with schizophrenia and a history of suicide attempts, patients with schizophrenia without suicidal tendencies, and healthy control volunteers.
METHODS: Relapses according to gender and age were examined in 47 patients with schizophrenia with suicidal behavior, 47 patients without self-destructive conditions, and 47 volunteers with healthy control and maintenance for the content of telomeric and the number of copies of mitochondrial DNA (mtDNA) in peripheral blood leukocytes.
RESULTS: Analysis of determining the content of telomeric repeat (TR) in the DNA of massive weight gain in the series: patients with schizophrenia and suicidal attempts — patients with schizophrenia without suicidal observations — healthy controls (225±28.4 (227 [190; 250]) vs. 243±21 (245 [228; 260]) vs. 255±17.9 (255 [242; 266]), p <0.005. The same trend is observed for the number of mtDNA copies (257±101.5 (250 [194; 297])) vs. 262.3±59.3 (254 [217; 312]) vs. 272±79.9 (274 [213; 304]); p=0.012), but no significant differences were recorded.
CONCLUSIONS: For the first time, the phenomenon of telomere shortening was discovered in schizophrenics with suicidal risk. The length of the telomere corresponds to the parameter of a biological marker — an objectively measured indicator of normal or pathological processes, but gaining an idea of its reliability is still necessary for verification with an assessment of its sensitivity, specificity, and positive and negative predictive value. The telomere may be considered a putative predictive indicator of suicidal risk.
АННОТАЦИЯ
ВВЕДЕНИЕ: Шизофрения и суицидальное поведение сопряжены с укорочением длины теломер. Целью исследования стало сравнение содержания (пг/мкг) теломерного повтора в ДНК, выделенной из клеток периферической крови, у трех групп испытуемых: пациентов с шизофренией и суицидами в анамнезе, пациентов с шизофренией без суицидов и добровольцев из числа здорового контроля.
Длина теломер как маркер суицидального риска при шизофрении
doi: 10.17816/CP171
Original research
Natalia Zakharova,1 Lidia Bravve,1 Galina Mamedova,1 Maria Kaydan,1 Elizaveta Ershova,2 Andrey Martynov,2 Natalia Veiko,2 Svetlana Kostyuk2
1 Mental Health dinic No.1 named after N.A. Alexeev, Moscow, Russia
2 Research Center for Medical Genetics, Department of Molecular Biology, Moscow, Russia
Наталья Захарова,1 Лидия Бравве,1 Галина Мамедова,1 Мария Кайдан,1 Елизавета Ершова,2 Андрей Мартынов,2 Наталья Вейко,2 Светлана Костюк2
1 ГБУЗ «Психиатрическая клиническая больница № 1 им. Н.А. Алексеева Департамента здравоохранения города Москвы», Москва, Россия
2 ФГБНУ «Медико-генетический научный центр им. Н.П. Бочкова», Москва, Россия
ABSTRACT
МЕТОДЫ: Обследованы сопоставимые по полу и возрасту 47 пациентов с шизофренией с суицидальным поведением, 47 больных без аутодеструктивных тенденций и 47 добровольцев здорового контроля клинически и на предмет содержания теломерного повтора в ДНК лейкоцитов крови.
РЕЗУЛЬТАТЫ: Анализ определения содержания теломерного повтора (TR) в ДНК свидетельствует о статистически значимом увеличении длины теломер в ряду: пациенты с шизофренией и суицидами — пациенты с шизофренией без суицидов — здоровый контроль (225 vs 224 vs 255; р=0,024). Такой же тренд прослеживается для концентрации митохондриальной ДНК (мтДНК) (257 vs 262 vs 272; р=0,012).
ВЫВОДЫ: Впервые установили феномен укорочения длины теломер при шизофрении, сопряженной с суицидальным риском. Длина теломер отвечает параметрам биологического маркера — объективно измеряемого показателя нормальных или патологических процессов, но его валидность еще необходимо проверить с оценкой его чувствительности, специфичности, положительной и отрицательной прогностической ценности. Рассматривать длину теломер как прогностический индикатор суицидального риска преждевременно.
Keywords: schizophrenia; suicide; telomere length; mtDNA Ключевые слова: шизофрения; суицид; длина теломер; мтДНК
INTRODUCTION
When publishing the study methodology and results, we should note two important features of schizophrenia, which are hardly comparable in terms of the universal human values of the 21st century, but are relevant separately, especially in light of the active search for biomarkers in psychiatric disorders and the development of contemporary approaches to reduce the risk of adverse outcomes in schizophrenia.
On the one hand, real-world psychiatric clinical practice shows that self-destructive behavior is a major cause of premature death among patients with schizophrenia. The suicide rate among patients with schizophrenia is 5-10 times higher than in the general population [1-4], and 25-50% of schizophrenia patients will attempt suicide during their life time, with 5.6% of suicide attempts ultimately proving fatal [5]. The mean age of schizophrenic patients who commit suicide is just 33 years, which is 10 years lower than in the general population [6-8], and completed suicide accounts for 30.9% of deaths during the first-episode psychosis [9-12]. Comparison of suicidal risk indices between the different nosologic groups shows poor results: the proportion of patients with schizophrenia can constitute 45-65% of suicidal patients with all other established psychiatric disorders [13, 14], and the lifetime rate of suicide in individuals with schizophrenia is between 9% and 13% [12, 15].
Meanwhile, the scientific literature discusses the hypothesis of accelerated aging due to oxidative stress and chronic neuroinflammation as a cause of
schizophrenia [16-19]. According to this hypothesis, the oxidative stress associated with schizophrenia leads to premature degradation of cells and tissues, and endocrine and humoral abnormalities. All these factors, along with multiple decompensations, may lead to death 10-15 years earlier than otherwise expected [17, 20, 21]1.
Telomeres (TR), which are repetitive non-coding nucleotide sequences at the ends of the linear chromosomes (TTAGGG)n coated with binding proteins, are considered to be a 'biological counter' of the cell division number. Telomere shortening is directly and reliably associated with aging. A critical telomer length triggers the process of programmed cell death, which is accelerated in chronic cardiovascular disorders, metabolic syndrome, diabetes mellitus, and psychiatric disorders [24]. Telomere length homeostasis is achieved via a balance between the telomer erosion over successive eukaryotic cell divisions and telomere lengthening via telomerase, which adds repetitive nucleotide sequences to the 3' end of the DNA strand [24]. Oxidative stress is a major cause of direct telomere shortening. It has been established that 8-oxo-7,8-dihydro-2'-deoxyguanosine, a product of guanosine oxidation via hydroxyl radicals, is formed in larger amounts in a telomeric DNA sequence than in a non-telomeric DNA sequence [25].
1 Other factors associated with schizophrenia may lead to abnormalities, e.g. higher smoking rates among patients with schizophrenia than in general population [22], poor quality of healthcare [23].
The length of the telomeres is defined by their content in the total DNA volume.
Mitochondrial DNA (mtDNA) copy number variation is considered to be a tandem marker for assessing the function of the 'biological counter' of telomere shortening. This marker reflects mitochondrial dysfunction, i.e., loss of reserve energy-generating capacity, especially in settings such as stress and psychiatric disorders [26-28].
Mitochondria not only provide the cell with necessary energy reserves, but also play a key role in the processes of apoptotic and necrotic cell death, regulation of gene expression, and the signaling pathways of cell proliferation and differentiation [29]. Mitochondrial biogenesis, determined by mtDNA copy number, may serve to compensate for increased energy demand or decreased mitochondrial function and is associated with aging and age-related diseases [30]. Several groups of researchers reported reduced leukocyte and whole blood mtDNA copy number in patients with psychiatric disorders, compared to healthy controls [31-34].
An analysis of publications on telomere shortening in schizophrenia and suicide reveals certain features. Controversial data2 on telomere length in schizophrenia relative to healthy controls has been reported in the literature, but the results of meta-analyses [19, 41] demonstrate a significant telomer shortening in young patients with schizophrenia spectrum disorders [42]. These results were replicated in a tandem (combined) analysis of the telomere content and leukocyte mtDNA copies in young and middle-aged individuals [43, 44]. More significant correlation was observed in groups of patients with signs of psychiatric or developmental disorders [45].
The results of the studies on the telomer length and mtDNA in suicidal individuals without schizophrenia are sustained and reproducible. Comparison of samples obtained from 528 suicidal individuals and 560 subjects who died from other causes demonstrated significant telomer shortening in the brain tissue and blood cells [46]. Analysis of completed suicide cases showed shorter telomeres in female/young suicides and higher mtDNA content in male/elderly suicides [46]. These results were confirmed by comparison of telomere
2 A number of studies have reported [21, 35, 36] an association between telomere shortening and schizophrenia, but these data have not been confirmed in other studies that have demonstrated longer telomeres in patients with schizophrenia [37], or no differences between these patients and healthy controls [38-40].
length in 71 suicidal individuals [47], which leads to the conclusion that telomere length is inversely associated with the risk of suicide in patients younger than 50 years old, including those with affective disorders [48].
As there are no available data on telomere length comparisons in suicidal patients with schizophrenia, we hypothesized that telomeres are shorter in patients with schizophrenia and a history of suicidal behavior relative to patients with schizophrenia without self-destructive behavior or healthy controls.
The aim of the study was to compare the content (pg/pg) of the telomeric repeats and the mtDNA copy number in the genome of peripheral blood cells in three groups of subjects: patients with schizophrenia and a history of suicidal behavior, patients with schizophrenia without suicidal tendencies, and healthy volunteers.
MATERIALS AND METHODS
The study population includes 94 patients with schizophrenia (55 males, 39 females, mean age 27.3± 8.6 years) who were admitted to the acute pathology units of the SBHI 'Psychiatric Clinical Hospital No.1 of the Moscow Healthcare Department' from February to March 2019.
Inclusion criteria
The patient's condition on evaluation meets the ICD-10 diagnostic criteria for schizophrenia; the patient has signed the Informed Consent Form.
Non-inclusion criteria
Severe decompensated somatic disorder; signs of psychoactive substance or alcohol abuse; pregnancy; refusal to participate.
To confirm the proposed hypothesis three groups of patients were formed based on the presence of suicidal behavior:
• group 1 (n=47, mean age 25±6.6 years, 30 males (64%)): patients with schizophrenia and a history of at least one suicide attempt;
• group 2 (n=47, mean age 29.5±9.8 years, 25 males (53%)): patients with schizophrenia without a history of suicidal ideation or behavior;
• control group (n=47, mean age 26±3.9 years, 22 males (47%)): healthy subjects without signs of psychiatric disorders and non-relatives of patients.
Study design: non-interventional, cross-sectional, case-control study.
Methods
Clinical and psychometric approaches were used to assess the patient's condition and analyze their history. The Positive and Negative Syndrome Scale (PANSS) was used to evaluate the patient's condition, taking into account the Positive (PANSS P), Negative (PANSS N) and General Psychopathology (PANSS G) subscale scores [49].
Blood sampling from the cubital vein was performed once at 8.00 to 8.30 a.m. after overnight fasting; samples were drawn into heparin tubes and sent to the laboratory within two hours in compliance with requirements regarding biomaterial preservation.
Molecular biology method was used to measure the telomere and mtDNA content in samples obtained from patients in three study groups.
The result of telomere content measurement was expressed as pg/pg of DNA, and the result of mtDNA content measurement was expressed as the copy number in the genome.
We used the quantitative non-radioactive hybridization (NQH) assay, specially designed for the quantitative analysis of tandem repeats in the genome. The NQH method has been detailed in several publications [50-52]. DNA was isolated from blood by extraction with organic solvents. The DNA concentration in the solution was measured via fluorimetry using PicoGreen dye (Invitrogene). The NQH method is based on the hybridization of denatured DNA samples applied to a filter (50 ng/spot) with a biotinylated DNA probe that is complementary to the DNA fragment of interest. The biotin-(TTAGGG)7 oligonucleotide (Sintol, Russia) was used as a DNA probe. The streptavidin-alkaline-phosphatase conjugate (Sigma) was used to detect biotin after hybridization. Alkaline phosphatase substrates (BCIP/NBT) in the presence of the enzyme form an insoluble precipitate, which is adsorbed on the filter at the DNA target location. When the reaction ends, the filter is scanned and integral intensity (I) of the spots is determined using a special program. Several DNA calibration standards with a known TR content are applied to the same filter. The calibration dependence relates the signal (I) to the number of repeats in 50 ng of DNA. An example of a calibration dependence for telomeres is given in one of our previous publications [53]. The standard error of the NQH method is 5% of the measured value. The total error of the method, which includes DNA isolation,
determination of the DNA concentration in solution, and hybridization, is 11%.
Assay for mtDNA quantification
Quantitative PCR assay (RT-PCR) was used to analyze the mtDNA copy number in DNA. The methodology and primers for mtDNA analysis are described in detail in the publication [53].
Statistical data analysis was carried out using the Jamovi software (The Jamovi Project (2022)). jamovi. (Version 2.3) [Computer Software], https://www.jamovi.org.). Descriptive statistics include medians and quartiles. T-test with indication of the degrees of freedom (df), t-test parameter (t) and a 95% confidence interval (95% CI) were used for analysis of the psychometric scale scores, as well as clinical and dynamic characteristics. The MannWhitney test (U-test) with the calculation of all test parameters was used to compare the molecular testing results in gender groups. The Kruskal-Wallis test was used for statistical analysis of group data via continuous variables, and the Dwass, Steel, Critchlow-Fligner test (DSCF pairwise comparison) was used to test paired hypotheses. Correlation between variables was assessed using Pearson's x2 test. For all tests, data were considered statistically significant at a two-sided p <0.05.
RESULTS
The results of clinical, psychometric, and molecular testing are presented in Tables 1, 2, 3, and 4.
The groups were matched for gender, although the number of men in group 1 (patients with suicide attempts) was higher than in the control group — 64% vs. 47%), however, this difference was not statistically significant.
The vast majority of patients in each of the groups have impaired social functioning and live reclusive lives (the proportion of single patients was 80.9% in the study population, and 87.3 and 74.5% in the respective groups) and are persistently disabled in some cases (the proportion of disabled persons was 15% in the study population, and 13 and 17% in the respective groups). Analysis of environmental factors affecting telomere content and mtDNA copy number (smoking and metabolic syndrome) did not reveal significant differences between the groups (Table 1).
Clinical and dynamic characteristics of two groups were heterogeneous (Table 2).
Group 2 patients were significantly older than group 1 patients and the healthy controls.
Table 1. Socio-demographic characteristics and description of factors affecting the telomere length and cfDNA concentration in the study groups
Characteristics Group 1 n=47 Group 2 n=47 X2 (p) Control n=47 X2 (P1) X2 (p2)
Socio-demographic characteristics, abs. (%)
Males 30 (64%) 25 (53%) 1.096 (0.3) 22 (47%) 2.755 (0.1) 0.383 (0.5)
Single 41 (87.3%) 35 (74.5%) 2.474 (0.1) 27 (57.4%) 10.421 (0.001) * 3.032 (0.1)
Disabled 6 (13%) 8 (17%) 0.336 (0.6) 0 - -
Telomer shortening risk factors, abs. (%)
Smoking 13 (27.6%) 7 (14.8%) 2.287 (0.1) 8 (17%) 1.533 (0.2) 0.079 (0.8)
Metabolic syndrome 4 (8.5%) 4 (8.5%) 0 (1) 3 (6%) 0.111 (0.7) 0.111 (0.7)
Note: p — differences between the study groups; pi — differences between the control group and the group of patients with schizophrenia and a history of at least one suicide attempt; p2 — differences between the control group and the group of patients with schizophrenia without a history of suicidal ideation or behavior; * — statistically significant difference when using Chi-Squared test.
Table 2. Clinical and dynamic characteristics of schizophrenia in study groups
Value Group 1 n=47 Group 2 n=47 Control n=47
Years±SD Years±SD p (df) (t) [95% CI] Years±SD p 1 (df) (t) [95% CI] p 2 (df) (t) [95% CI]
Mean age 25±6.6 29.5±9.8 0,010* (92) (2.6) [7.9-1.1] 26±3.9 0.404 (92) (0.8) [3.2-1.3] 0,023* (92) (2.3) [0.5-6.6]
Mean age at onset 18.7±6.5 19.1±6 0.743 (92) (0.3) [3-2.1] - - -
Disease duration 6.3±6.0 10.4±8.5 0,008* (92) (2.7) [7.1-1.1] - - -
Mean AP dose, mg/day** 400±27.3 300±19.5 < 0.001* (92) (20.5) [90.7-110] - - -
Note: p — differences between the study groups; pi — differences between the control group and the group of patients with schizophrenia and a history of at least one suicide attempt; p2 — differences between the control group and the group of patients with schizophrenia without a history of suicidal ideation or behavior; * — statistically significant difference when using the t-test; **AP — antipsychotic chlorpromazine equivalents [54].
Further, in both groups the onset of schizophrenia was found to begin during late puberty or adolescence (18.7±6.5 vs. 19.1±6; p=0.74), and therefore the disease duration is significantly shorter in patients with suicide attempts than in patients without suicidal ideation (6.3±6.0 vs 10.4±8.5; p=0.0083). Moreover, the statistically significant difference in antipsychotic dosage should be noted: group 1 patients receive more intensive treatment (400±27 vs. 300±20 mg/day of chlorpromazine equivalent; p <0.0001).
Table 3 shows the results of psychometric testing in the two groups of patients: statistically significant differences
were found in the severity of negative symptoms, as measured by the PANSS-N subscale mean score (27.4 vs 22.8 points; p=0.0052), while no differences were found in the total score or Positive and General Psychopathology subscale scores.
Results of telomere content measurement (Table 4) show a statistically significant difference in telomere length between the three groups (p <0.001; x2=24.8; df=2). DSCF pairwise comparisons revealed significant differences in telomere length between some groups. Statistically significant differences in telomere content were found
Table 3. Results of psychometric testing in the study groups
Scale Group 1 Group 2 P
n=47 n=47 (df) (t)
Total score mean±SD (Me [Q1; Q3]) Total score mean±SD (Me [Q1; Q3]) [95% CI]
PANSS total score 101.2±23.1 94.9±26.3 0.223
(97 [86; 112]) (94 [76; 112]) (92) (1.2)
[3.9-16.4]
PANSSP 23.8±7.6 24.9±8.5 0.522
(23 [18; 27]) (23 [20; 29]) (92) (0.6)
[4.4-2.2]
PANSS N 27.4±8.8 22.8±6.6 0.005*
(26 [22; 33]) (11 [19; 28]) (92) (2.9)
[1.4-7.8]
PANSS G 50±10.9 47.2±15.3 0.318
(49 [44; 59]) (48 [39; 59]) (92) (1)
[2.7-8.2]
Biomarker concentrations Group 1 n=47 Total score mean±SD (Me [Q1; Q3]) Group 2 n=47 Total score mean±SD (Me [Q1; Q3]) Control n=47 Total score mean±SD (Me [Q1; Q3]) P* (X2*) (df*)
Telomers 225±28.4 243±21 255±17.9 < 0.001**
(pg/mcg DNA) (227 [190; 250]) (245 [228; 260]) (255 [242; 266]) (24.8)
(2)
mtDNA (copy number) 257±101.5 (250 [194; 297]) 262.3±59.3 (254 [217; 312]) 272±79.9 (274 [213; 304]) 0.579 (1.09) (2)
* — The Kruskal-Wallis test was used for the analysis, the statistics for which are given in parentheses: x2 — chi-squared; df — degrees of freedom.
** — The Kruskal-Wallis test revealed a statistically significant difference in the three study groups. The BSCF test was used for pairwise comparison, and a significant difference in telomere content was found between group 1 and group 2, group 1 and the control group, and group 2 and the control group.
Note: * — Statistically significant difference when using the t-test. Table 4. Molecular testing results
between the group of patients with a history of suicide attempts and the group of patients without suicidal ideation (225 pg/mcg±28.4 (227 [190; 250]) vs. 243 pg/mcg± 21 (245 [228; 260]); p=0.007; W=2.3). Statistically significant differences in telomere content were found between the group of patients with a history of suicide attempts and the control group (225 pg/mcg±28.4 (227 [190; 250]) vs. 255 pg/mcg±17.9 (255 [242; 266]); p <0.001; W=6.7) and between the group of patients without suicidal ideation and healthy controls (243 pg/mcg±21 (245 [228; 260]) vs. 255 pg/mcg±17.9 (255 [242; 266]); p=0.041; W=3.4). There were no significant differences in mtDNA copy number between the three study groups (p=0.579; x2=1.09; df=2).
Comparison of the telomere and mtDNA content in male patients (Table 5) shows statistically significant differences:
the telomer content was significantly lower in males with a history of suicide attempts compared to those without suicidal ideation (216±27.1 (208 [193; 242]) vs. 240.9±25.7 (250 [219; 260]); p=0.002, U-test=198), while the mtDNA content was reduced without statistically significant differences. Amongst women, there were no statistically significant differences in the telomere and mtDNA content between the two groups.
DISCUSSION
Before the discussion of the results, we would like to emphasize that the significant telomere shortening demonstrated in our study cannot serve as definitive biological evidence of completed suicide predetermination in patients with schizophrenia, even though other studies
Table 5. Molecular testing results by gender
Biomarker concentrations in male patients in the two study groups
Data Group 1 Males (n=30) Total score mean±SD (Me [Q1; Q3]) Group 2 Males (n=26) Total score mean±SD (Me [Q1; Q3]) p (Mann-Whitney U) (U-test) [95% CI]
Telomers (pg/mcg DNA) 216±27.1 (208 [193; 242]) 240.9±25.7 (250 [219; 260]) 0.002* (198) [43-10]
mtDNA (copy number) 246±104.1 (252 [158; 289]) 280±61 (255 [244; 255]) 0.130 (298) [85-6]
Biomarker concentrations in female patients in the two study groups
Data Group 1 Female (n=17) Total score mean±SD (Me [Q1; Q3]) Group 2 Female (n=21) Total score mean±SD (Me [Q1; Q3]) p (Mann-Whitney U) (U-test) [95% CI]
Telomers (pg/mcg DNA) 241±24 (249 [227; 253]) 245±15 (245 [233; 254]) 0.692 (165) [15-10]
mtDNA (copy number) 276±97 (234 [226; 339])] 277±66 (254 [225; 318]) 0.837 (171) [55-38]
Note: * — Statistically significant difference when using the U-test.
demonstrate telomere shortening and a decrease in the mtDN copy number in the cells of postmortem specimens from suicide completers compared with those who died from other causes [46].
Clinical assessment of risk of suicide in schizophrenia is based on the identification of symptomatic, environmental, and behavioral factors such as gender, age, history of suicide attempts, family history of suicides, etc. A meta-analysis has shown that the risk of suicide is highest in young men with a history of suicide attempts and a poor compliance with psychopharmacotherapy [55]. According to the literature, clinical and dynamic risk factors of suicide in schizophrenia are the signs of an unfavorable disease course (early disease onset with frequent relapses and hospitalizations, need for high-dose antipsychotics [56-59] and long-term psychiatric hospitalization [60-62]), which are associated with the negative symptom severity and social maladaptation [63], and which may lead to telomere shortening to a greater extent [64].
In this study, we identified the risk factors of unfavorable course of schizophrenia in both groups, but their significance in terms of risk of suicide cannot be considered reliable. Thus, male patients are predominant in the study population, but this parameter is statistically insignificant (64% vs. 53%; p=0.3). Patients with a history of suicide attempts were younger at the onset of schizophrenia, but the difference in this parameter was not statistically
significant (18.7±6.5 vs. 19.1 ±6.0 years; p=0.74). Meanwhile, in the group of patients with a history of suicide attempts, statistically significant differences in the PANSS-N score — a measure of negative symptom severity associated with an unfavorable course of schizophrenia — was observed (27.4±8.8 (26 [22; 33]) vs. 22.8±6.6 (11 [19; 28]) points; p=0.0052). According to the literature, this parameter can be directly correlated with reduced telomere and mtDNA content [65].
Significant differences in disease duration were found; however, disease duration was shorter in patients with a history of suicide attempts (6.3 vs. 10.4 years; p=0.0083), that is, the more prominent telomere shortening in this group compared to the patients without suicidal ideation can be explained not only by the course of psychiatric disorder, but by a combination of several factors, which is consistent with the results of telomere evaluation at different stages of schizophrenia [65].
First, antipsychotic agents provide active telomerase expression via transcription factor 4 (TCF4) activation in the presence of protein kinase-B (alpha serine/ threonine-protein kinase, Protein kinase B alpha, Akt1) and glycogen synthase-3-p-catenin (glycogen synthase kinase GSK3P) that block type 2 dopamine and/or serotonin receptors [66]. In schizophrenia, GSK3p is activated and Akt1 is inhibited both in the cells of the cerebral cortex and the blood [67], and this is can be directly correlated
with TCF4 deactivation and telomere shortening [64]. Antipsychotics increase serine phosphorylation of GSK3P [68] and block both D2- and 5-HT2A receptors, thus increasing telomerase synthesis, which, in turn, leads to telomere shortening. In this study, patients with a history of suicide attempts received antipsychotics in typical therapeutic doses (400 mg/day vs. 300 mg/day of chlorpromazine equivalent; p >0.05), which could lead to telomer shortening. On the other hand, treatment response is an important predictor of telomere length, and there is some evidence that therapy-resistant patients have shorter telomeres compared to healthy individuals and patients in remission [69, 70]. It has been found that many antipsychotics, including clozapine, risperidone, haloperidol, olanzapine, and chlorpromazine, may inhibit the respiratory chain and cause mitochondrial damage by increasing oxidative stress [71], which may also explain the reduced mtDNA content, as shown in a similar study [28].
Secondly, factors exacerbating the consequences of oxidative stress [72], such as smoking [35, 37, 38, 40, 70] and metabolic syndrome as a pro-inflammatory process [73], cause telomere shortening. There was no statistically significant difference in the number of smokers and patients with metabolic syndrome between all groups, hence the difference in telomere and mtDNA content may be a coincidence and not a trend, as shown in a number of studies [74].
Although our results partially reproduce the literature data, it must be reiterated that the causes of telomere shortening in schizophrenia or suicide may be different. In addition to the natural telomere shortening with each cell division, oxidative stress, and chronic inflammation play a significant role [75]. It seems more likely that the reduction in telomere content and mtDNA copy number may be the result of cumulative exposure to the chronic stress associated with schizophrenia [76].
CONCLUSIONS
In this study, we, for the first time, identified the phenomenon of telomere shortening in schizophrenia associated with suicidal risk. However, we emphasize that it would be premature to consider telomere length a prognostic indicator of risk of suicide. Undoubtedly, telomere length has all features of a biomarker, i.e., objectively measured index of normal or abnormal processes, but its validity still needs to be verified through an assessment of its sensitivity,
specificity, and positive and negative predictive value. An analysis of the factors affecting telomere length (smoking, metabolic disorders, antipsychotic therapy) in the study participants does not demonstrate a direct relationship between telomere shortening and risk of suicide amongst those with schizophrenia.
The study limitations were relatively small sample size and failure to account for additional factors that affect the qualitative characteristics of the studied markers. The latter include, for example, gender differences in suicidal behavior or the father's age at conception [40, 77, 78]. The telomere content and mtDNA copy number in the nucleus of peripheral blood leukocytes may differ from those in other tissues (for example, neurons) due to the fact that antipsychotics reduce telomerase expression in leukocytes [64].
It seems promising to search for possible protective factors (for example, telomerase inhibitors), which may act as triggers for the development of a specific therapy to reduce suicidal tendencies by slowing the rate of telomer shortening. However, identification of such trends may contribute to the development of alternative agents that will reduce the impact of oxidative stress and slow telomere shortening within this patient population.
Article history:
Submitted: 29.03.2022 Accepted: 30.05.2022 Published: 21.06.2022
Funding: The study was supported by the Russian Science Foundation grant No. 18-15-00437 and conducted within the framework of the state task given by the Moscow Healthcare Department. Funding sources (RSF and Moscow Healthcare Department) and manufacturers of devices involved in the project did not influence the results and opinion of the authors at all study stages (design development, data collection and analysis, result interpretation or reporting). The authors have access to all data at all stages of work, and the decision to publish the results was agreed with the administration of the Research and Clinical Center for Neuropsychiatry of the SBHI Psychiatric Clinical Hospital No.1 of the Moscow Healthcare Department.
Conflict of interest: The authors declare no conflicts of interest.
Compliance with principles of bioethics: The data presented in this publication are a part of the Molecular and Neurophysiological Markers of Endogenous Diseases Research Program, conducted at the SBHI Psychiatric Clinical Hospital No.1 of the Moscow Healthcare Department and approved by the Independent Interdisciplinary Ethics Committee on Ethical Review for Clinical Studies on July 14, 2017 (protocol No. 12).
For citation:
Zakharova NV, Bravve LV, Mamedova GSh, Kaydan MA, Ershova ES, Martynov AV, Veiko NN, Kostyuk SV. Telomere length as a marker of suicidal risk in schizophrenia. Consortium Psychiatricum 2022;3(2):37-47. doi: 10.17816/CP171
Information about the authors
*Zakharova Natalia Vyacheslavovna, PhD, MD, Head of the Laboratory for Fundamental Research Methods of the Scientific Research Center of Neuropsychiatry, Mental Health Clinic No.1 n.a. N.A. Alexeev, ORCID: https://orcid.org/0000-0001-7507-327X E-mail: [email protected]
Bravve Lidia Victorovna, MD, psychiatrist, junior researcher of the Laboratory for Fundamental Research Methods of the Scientific Research Center of Neuropsychiatry, Mental Health Clinic No.1 n.a. N.A. Alexeev, ORCID: https://orcid.org/0000-0001-5380-4406 Mamedova Galina Shakirovna, clinical resident, assistant of the Laboratory for Fundamental Research Methods of the Scientific Research Center of Neuropsychiatry, Mental Health Clinic No.1 n.a. N.A. Alexeev, ORCID: https://orcid.org/0000-0003-4481-7840 Kaydan Maria Andreevna, MD, psychiatrist, junior researcher of the Laboratory for Fundamental Research Methods of the Scientific Research Center of Neuropsychiatry, Mental Health Clinic No.1 n.a. N.A. Alexeev, ORCID: https://orcid.org/0000-0002-1516-082 Ershova Elizaveta Sergeevna, PhD in Biology, leader scientific researcher of the Laboratory of Molecular Biology of the Research Centre for Medical Genetics (RCMG), ORCID: https://orcid.org/0000-0003-1206-5832 Martynov Andrey Vladimirovich, PhD in Biology, senior scientific researcher of the Laboratory of Molecular Biology of the Research Centre for Medical Genetics (RCMG)
Veiko Natalia Nikolaevna, PhD in Biology, chief scientific researcher of the Laboratory of Molecular Biology of the Research Centre for Medical Genetics (RCMG)
Kostyuk Svetlana Victorovna, PhD in Biology, Head of the Laboratory of Molecular Biology of the Research Centre for Medical Genetics (RCMG)
*corresponding author References
1. Nordentoft M, Jeppesen P, Abel M, Kassow P, Petersen L,
Thorup A, Krarup G, Hemmingsen R, Jorgensen P. OPUS study: suicidal behaviour, suicidal ideation and hopelessness among patients with first-episode psychosis. One-year follow-up of a randomised controlled trial. Br J Psychiatry Suppl. 2002 Sep;43:s98-106. doi: 10.1192/bjp.181.43.s98.
2. Saha S, Chant D, McGrath J. A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? Arch Gen Psychiatry. 2007 Oct;64(10):1123-1131.
doi: 10.1001/archpsyc.64.10.1123.
3. Moussaoui D, El Hamaoui Y. Faculty Opinions recommendation of A systematic review of mortality in schizophrenia: is the differential mortality gap worsening over time? // Faculty Opinions — Post-Publication Peer Review of the Biomedical Literature. 2008.
4. Luhr R, Cao Y, Soderquist B, Cajander S. Trends in sepsis mortality over time in randomised sepsis trials: a systematic literature review and meta-analysis of mortality in the control arm, 2002-2016.
Crit Care. 2019 Jul 3;23(1):241. doi: 10.1186/s13054-019-2528-0.
5. Hor K, Taylor M. Suicide and schizophrenia: a systematic review of rates and risk factors. J Psychopharmacol. 2010 Nov;
24(4 Suppl):81-90. doi: 10.1177/1359786810385490.
6. Roy A, Pompili M. Management of schizophrenia with suicide risk. Psychiatr Clin North Am. 2009 Dec;32(4):863-883.
doi: 10.1016/j.psc.2009.08.005.
7. Pompili M, Fiorillo A. Preventing Suicide in Patients with Mental Disorders. Basel: MDPI; 2020. 148 p.
8. Sadek J. A Clinician's Guide to Suicide Risk Assessment and Management. Springer; 2018. 113 p.
9. Agerbo E. High income, employment, postgraduate education, and marriage: a suicidal cocktail among psychiatric patients. Arch Gen Psychiatry. 2007 Dec;64(12):1377-1384.
doi: 10.1001/archpsyc.64.12.1377.
10. Healy D, Le Noury J, Harris M, Butt M, Linden S, Whitaker C, Zou L, Roberts AP. Mortality in schizophrenia and related psychoses: data from two cohorts, 1875-1924 and 1994-2010. BMJ Open. 2012;2(5). doi: 10.1136/bmjopen-2012-001810.
11. Montross LP, Zisook S, Kasckow J. Suicide Among Patients with Schizophrenia: A Consideration of Risk and Protective Factors. Annals of Clinical Psychiatry. 2005;17(3):173-182.
12. Kasckow J, Felmet K, Zisook S. Managing suicide risk in patients with schizophrenia. CNS Drugs. 2011 Feb;25(2):129-143.
doi: 10.2165/11586450-000000000-00000.
13. Thong JY, Su AH, Chan YH, Chia BH. Suicide in psychiatric patients: case-control study in Singapore. Aust N Z J Psychiatry. 2008 Jun;42(6):509-519. doi: 10.1080/00048670802050553.
14. Hunt IM, Kapur N, Webb R, Robinson J, Burns J, Shaw J, Appleby L. Suicide in recently discharged psychiatric patients: a case-control study. Psychol Med. 2009 Mar;39(3):443-449. doi: 10.1017/S0033291708003644.
15. Miles CP. Conditions predisposing to suicide: a review. J Nerv Ment Dis. 1977 Apr;164(4):231-246. doi: 10.1097/00005053-197704000-00002.
16. Kirkpatrick B, Messias E, Harvey PD, Fernandez-Egea E, Bowie CR. Is schizophrenia a syndrome of accelerated aging? Schizophr Bull. 2008 Nov;34(6):1024-1032. doi: 10.1093/schbul/sbm140.
17. Shivakumar V, Kalmady SV, Venkatasubramanian G, Ravi V, Gangadhar BN. Do schizophrenia patients age early? Asian J Psychiatr. 2014 Aug;10:3-9. doi: 10.1016/j.ajp.2014.02.007.
18. Okusaga OO. Accelerated aging in schizophrenia patients: the potential role of oxidative stress. Aging Dis. 2014 Aug; 5(4):256-262. doi: 10.14336/AD.2014.0500256.
19. Polho GB, De-Paula VJ, Cardillo G, dos Santos B, Kerr DS. Leukocyte telomere length in patients with schizophrenia: A meta-analysis. Schizophr Res. 2015 Jul;165(2-3):195-200. doi: 10.1016/j.schres.2015.04.025.
20. Papanastasiou E, Gaughran F, Smith S. Schizophrenia as segmental progeria. J R Soc Med. 2011 Nov;104(11):475-484. doi: 10.1258/jrsm.2011.110051.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
46
Savolainen K, Raikkonen K, Kananen L, Kajantie E, Hovatta I, Lahti M, Lahti J, Pesonen AK, Heinonen K, Eriksson JG. History of mental disorders and leukocyte telomere length in late adulthood: the Helsinki Birth Cohort Study (HBCS). J Psychiatr Res.
2012 0ct;46(10):1346-1353. doi: 10.1016/j.jpsychires.2012.07.005. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophr Res. 2005 Jul 15;76(2-3):135-157. doi: 10.1016/j.schres.2005.02.010.
Mittal D, Corrigan P, Sherman MD, Chekuri L, Han X, Reaves C, Mukherjee S, Morris S, Sullivan G. Healthcare providers' attitudes toward persons with schizophrenia. Psychiatr Rehabil J.
2014 Dec;37(4):297-303. doi: 10.1037/prj0000095.
Eitan E, Hutchison ER, Mattson MP. Telomere shortening in neurological disorders: an abundance of unanswered questions. Trends Neurosci. 2014 May;37(5):256-263. doi: 10.1016/j.tins.2014.02.010. Kawanishi S, Oikawa S. Mechanism of telomere shortening by oxidative stress. Ann N Y Acad Sci. 2004 Jun;1019:278-284. doi: 10.1196/annals.1297.047.
Hossein Fatemi S. The Molecular Basis of Autism. Springer, 2015. 437 p. Kim JH, Kim HK, Ko JH, Bang H, Lee DC. The relationship between leukocyte mitochondrial DNA copy number and telomere length in community-dwelling elderly women. PLoS One. 2013;8(6):e67227. doi: 10.1371/journal.pone.0067227. Li Z, Hu M, Zong X, He Y, Wang D, Dai L, Dong M, Zhou J, Cao H, Lv L, et al. Association of telomere length and mitochondrial DNA copy number with risperidone treatment response in first-episode antipsychotic-naive schizophrenia. Sci Rep.
2015 Dec 18;5:18553. doi: 10.1038/srep18553.
Picard M, Zhang J, Hancock S, Derbeneva O, Golhar R, Golik P, O'Hearn S, Levy S, Potluri P, Lvova M, et al. Progressive increase in mtDNA 3243A>G heteroplasmy causes abrupt transcriptional reprogramming. Proc Natl Acad Sci U S A. 2014 Sep 23;111(38):E4033-4042. doi: 10.1073/pnas.1414028111. Lagouge M, Larsson NG. The role of mitochondrial DNA mutations and free radicals in disease and ageing. J Intern Med.
2013 Jun;273(6):529-543. doi: 10.1111/joim.12055.
Spano L, Etain B, Meyrel M, Hennion V, Gross G, Laplanche JL, Bellivier F, Marie-Claire C. Telomere length and mitochondrial DNA copy number in bipolar disorder: identification of a subgroup of young individuals with accelerated cellular aging. Transl Psychiatry. 2022 Apr 1;12(1):135. doi: 10.1038/s41398-022-01891-4. Wang D, Li Z, Liu W, Zhou J, Ma X, Tang J, Chen X. Differential mitochondrial DNA copy number in three mood states of bipolar disorder. BMC Psychiatry. 2018 May 25;18(1):149. doi: 10.1186/s12888-018-1717-8.
Kageyama Y, Deguchi Y, Kasahara T, Tani M, Kuroda K, Inoue K, Kato T. Intra-individual state-dependent comparison of plasma mitochondrial DNA copy number and IL-6 levels in patients with bipolar disorder. J Affect Disord. 2022 Feb 15;299:644-651. doi: 10.1016/j.jad.2021.10.098.
Bhat AH, Dar KB, Anees S, Zargar MA, Masood A, Sofi MA, Ganie SA. Oxidative stress, mitochondrial dysfunction and neurodegenerative diseases; a mechanistic insight. Biomed Pharmacother. 2015 Aug;74:101-110. doi: 10.1016/j.biopha.2015.07.025. Fernandez-Egea E, Bernardo M, Heaphy CM, Griffith JK, Parellada E, Esmatjes E, Conget I, Nguyen L, George V, Stoppler H, et al. Telomere length and pulse pressure in newly diagnosed, antipsychotic-naive patients with nonaffective psychosis. Schizophr Bull. 2009 Mar;35(2):437-442. doi: 10.1093/schbul/sbn169.
36. Kao HT, Cawthon RM, Delisi LE, Bertisch HC, Ji F, Gordon D, Li P, Benedict MM, Greenberg WM, Porton B. Rapid telomere erosion in schizophrenia. Mol Psychiatry. 2008 Feb;13(2):118-119.
doi: 10.1038/sj.mp.4002105.
37. Nieratschker V, Lahtinen J, Meier S, Strohmaier J, Frank J, Heinrich A, Breuer R, Witt SH, Nothen MM, Rietschel M, et al. Longer telomere length in patients with schizophrenia. Schizophr Res. 2013 Sep;149(1-3):116-120.
doi: 10.1016/j.schres.2013.06.043.
38. Mansour H, Chowdari K, Fathi W, Elassy M, Ibrahim I, Wood J, Bamne M, Tobar S, Yassin A, Salah H, et al. Does telomere length mediate associations between inbreeding and increased risk for bipolar I disorder and schizophrenia? Psychiatry Res.
2011 Jun 30;188(1):129-132. doi: 10.1016/j.psychres.2011.01.010.
39. Zhang D, Cheng L, Craig DW, Redman M, Liu C. Cerebellar telomere length and psychiatric disorders. Behav Genet. 2010 Mar;40(2):250-254. doi: 10.1007/s10519-010-9338-0.
40. Malaspina D, Dracxler R, Walsh-Messinger J, Harlap S, Goetz RR, Keefe D, Perrin MC. Telomere length, family history, and paternal age in schizophrenia. Mol Genet Genomic Med.
2014 Jul;2(4):326-331. doi: 10.1002/mgg3.71.
41. Darrow SM, Verhoeven JE, Revesz D, Lindqvist D, Penninx BW, Delucchi KL, Wolkowitz OM, Mathews CA. The Association Between Psychiatric Disorders and Telomere Length:
A Meta-Analysis Involving 14,827 Persons. Psychosom Med. 2016 Sep;78(7):776-787. doi: 10.1097/PSY.0000000000000356.
42. Russo P, Prinzi G, Proietti S, Lamonaca P, Frustaci A, Boccia S, Amore R, Lorenzi M, Onder G, Marzetti E, et al. Shorter telomere length in schizophrenia: Evidence from a real-world population and meta-analysis of most recent literature. Schizophr Res. 2018 Dec;202:37-45. doi: 10.1016/j.schres.2018.07.015.
43. Tyrka AR, Parade SH, Price LH, Kao HT, Porton B, Philip NS, Welch ES, Carpenter LL. Alterations of Mitochondrial DNA Copy Number and Telomere Length With Early Adversity and Psychopathology. Biol Psychiatry. 2016 Jan 15;79(2):78-86. doi: 10.1016/j.biopsych.2014.12.025.
44. Kang JI, Park CI, Lin J, Kim ST, Kim HW, Kim SJ. Alterations of cellular aging markers in obsessive- compulsive disorder: mitochondrial DNA copy number and telomere length. J Psychiatry Neurosci. 2021 Jul 22;46(4):E451-E458. doi: 10.1503/jpn.200238.
45. Tyrka AR, Carpenter LL, Kao HT, Porton B, Philip NS, Ridout SJ, Ridout KK, Price LH. Association of telomere length and mitochondrial DNA copy number in a community sample
of healthy adults. Exp Gerontol. 2015 Jun;66:17-20. doi: 10.1016/j.exger.2015.04.002.
46. Otsuka I, Izumi T, Boku S, Kimura A, Zhang Y, Mouri K, Okazaki S, Shiroiwa K, Takahashi M, Ueno Y, et al. Aberrant telomere length and mitochondrial DNA copy number in suicide completers.
Sci Rep. 2017 Jun 9;7(1):3176. doi: 10.1038/s41598-017-03599-8.
47. Kim H, Cho SJ, Yoo SH, Kim SH, Ahn YM. Association between telomere length and completed suicide observed in 71 suicide victims — Preliminary findings. J Psychosom Res. 2019 May; 120:8-11. doi: 10.1016/j.jpsychores.2019.02.008.
48. Birkenaes V, Elvsashagen T, Westlye LT, Hoegh MC, Haram M, Werner MCF, Quintana DS, Lunding SH, Martin-Ruiz C, Agartz I, et al. Telomeres are shorter and associated with number of suicide attempts in affective disorders. J Affect Disord.
2021 Dec 1;295:1032-1039. doi: 10.1016/j.jad.2021.08.135.
49. Kay SR, Fiszbein A, Opler LA. The positive and negative syndrome scale (PANSS) for schizophrenia. Schizophr Bull. 1987;13(2):261-276. doi: 10.1093/schbul/13.2.261.
50. Ershova ES, Malinovskaya EM, Konkova MS, Veiko RV, Umriukhin PE, Martynov AV, Kutsev SI, Veiko NN, Kostyuk SV. Copy Number Variation of Human Satellite III (1q12) With Aging. Front Genet. 2019;10:704. doi: 10.3389/fgene.2019.00704.
51. Ershova ES, Jestkova EM, Martynov AV, Shmarina GV, Umriukhin PE, Bravve LV, Zakharova NV, Kostyuk GP, Saveliev DV, Orlova MD, et al. Accumulation of Circulating Cell-Free CpG-Enriched Ribosomal DNA Fragments on the Background of High Endonuclease Activity of Blood Plasma in Schizophrenic Patients. Int J Genomics. 2019;2019:8390585. doi: 10.1155/2019/8390585.
52. Chestkov IV, Jestkova EM, Ershova ES, Golimbet VE, Lezheiko TV, Kolesina NY, Porokhovnik LN, Lyapunova NA, Izhevskaya VL, Kutsev SI, et al. Abundance of ribosomal RNA gene copies
in the genomes of schizophrenia patients. Schizophr Res. 2018 Jul;197:305-314. doi: 10.1016/j.schres.2018.01.001.
53. Chestkov IV, Jestkova EM, Ershova ES, Golimbet VG, Lezheiko TV, Kolesina NY, Dolgikh OA, Izhevskaya VL, Kostyuk GP,
Kutsev SI, et al. ROS-Induced DNA Damage Associates with Abundance of Mitochondrial DNA in White Blood Cells of the Untreated Schizophrenic Patients. Oxid Med Cell Longev. 2018;2018:8587475. doi: 10.1155/2018/8587475.
54. Andreasen NC, Pressler M, Nopoulos P, Miller D, Ho BC. Antipsychotic dose equivalents and dose-years:
a standardized method for comparing exposure to different drugs. Biol Psychiatry. 2010 Feb 1;67(3):255-262. doi: 10.1016/j.biopsych.2009.08.040.
55. Cassidy RM, Yang F, Kapczinski F, Passos IC. Risk Factors for Suicidality in Patients With Schizophrenia: A Systematic Review, Meta-analysis, and Meta-regression of 96 Studies. Schizophr Bull. 2018 Jun 6;44(4):787-797. doi: 10.1093/schbul/sbx131.
56. De Hert M, McKenzie K, Peuskens J. Risk factors for suicide in young people suffering from schizophrenia: a long-term follow-up study. Schizophr Res. 2001 Mar 1;47(2-3):127-134.
doi: 10.1016/s0920-9964(00)00003-7.
57. Modestin J, Zarro I, Waldvogel D. A study of suicide in schizophrenic in-patients. Br J Psychiatry. 1992 Mar;160:398-401. doi: 10.1192/bjp.160.3.398.
58. Pinikahana J, Happell B, Keks NA. Suicide and schizophrenia:
a review of literature for the decade (1990-1999) and implications for mental health nursing. Issues Ment Health Nurs. 2003 Jan-Feb;24(1):27-43. doi: 10.1080/01612840305305.
59. Siris SG. Suicide and schizophrenia. J Psychopharmacol. 2001 Jun;15(2):127-135. doi: 10.1177/026988110101500209.
60. Pompili M, Amador XF, Girardi P, Harkavy-Friedman J, Harrow M, Kaplan K, Krausz M, Lester D, Meltzer HY, Modestin J, et al. Suicide risk in schizophrenia: learning from the past to change the future. Ann Gen Psychiatry. 2007 Mar 16;6:10. doi: 10.1186/1744-859X-6-10.
61. Altamura AC, Bassetti R, Bignotti S, Pioli R, Mundo E. Clinical variables related to suicide attempts in schizophrenic patients: a retrospective study. Schizophr Res. 2003 Mar 1;60(1):47-55. doi: 10.1016/s0920-9964(02)00164-0.
62. Mauri MC, Paletta S, Maffini M, Moliterno D, Altamura AC. Suicide attempts in schizophrenic patients: clinical variables. Asian J Psychiatr. 2013 Oct;6(5):421-427. doi: 10.1016/j.ajp.2013.07.001.
63. Bousman CA, Glatt SJ, Chandler SD, Lohr J, Kremen WS, Tsuang MT, Everall IP. Negative Symptoms of Psychosis Correlate with Gene Expression of the Wnt/beta-Catenin Signaling Pathway in Peripheral Blood. Psychiatry J. 2013;2013:852930. doi: 10.1155/2013/852930.
64. Porton B, Delisi LE, Bertisch HC, Ji F, Gordon D, Li P, Benedict MM, Greenberg WM, Kao HT. Telomerase levels in schizophrenia:
a preliminary study. Schizophr Res. 2008 Dec;106(2-3):242-247. doi: 10.1016/j.schres.2008.08.028.
65. Maurya PK, Rizzo LB, Xavier G, Tempaku PF, Ota VK, Santoro ML, Spindola LM, Moretti PS, Mazzotti DR, Gadelha A, et al. Leukocyte telomere length variation in different stages of schizophrenia. J Psychiatr Res. 2018 Jan;96:218-223.
doi: 10.1016/j.jpsychires.2017.10.016.
66. Beaulieu JM, Gainetdinov RR. The physiology, signaling, and pharmacology of dopamine receptors. Pharmacol Rev. 2011 Mar;63(1):182-217. doi: 10.1124/pr.110.002642.
67. Emamian ES, Hall D, Birnbaum MJ, Karayiorgou M, Gogos JA. Convergent evidence for impaired AKT1-GSK3beta signaling in schizophrenia. Nat Genet. 2004 Feb;36(2):131-137.
doi: 10.1038/ng1296.
68. Li X, Jope RS. Is glycogen synthase kinase-3 a central modulator in mood regulation? Neuropsychopharmacology. 2010 Oct; 35(11):2143-2154. doi: 10.1038/npp.2010.105.
69. Yu WY, Chang HW, Lin CH, Cho CL. Short telomeres in patients with chronic schizophrenia who show a poor response to treatment. J Psychiatry Neurosci. 2008 May;33(3):244-247.
70. Kota LN, Purushottam M, Moily NS, Jain S. Shortened telomere in unremitted schizophrenia. Psychiatry Clin Neurosci.
2015 May;69(5):292-297. doi: 10.1111/pcn.12260.
71. Kumar P, Efstathopoulos P, Millischer V, Olsson E, Wei YB, Brustle O, Schalling M, Villaescusa JC, Osby U, Lavebratt C. Mitochondrial DNA copy number is associated with psychosis severity and anti-psychotic treatment. Sci Rep. 2018 Aug 24;8(1):12743. doi: 10.1038/s41598-018-31122-0.
72. Roberts CK, Sindhu KK. Oxidative stress and metabolic syndrome. Life Sci. 2009 May 22;84(21-22):705-712. doi: 10.1016/j.lfs.2009.02.026.
73. Emanuela F, Grazia M, Marco de R, Maria Paola L, Giorgio F, Marco B. Inflammation as a Link between Obesity and Metabolic Syndrome. J Nutr Metab. 2012;2012:476380. doi: 10.1155/2012/476380.
74. Weischer M, Bojesen SE, Nordestgaard BG. Telomere shortening unrelated to smoking, body weight, physical activity, and alcohol intake: 4,576 general population individuals with repeat measurements 10 years apart. PLoS Genet. 2014 Mar; 10(3):e1004191.
doi: 10.1371/journal.pgen.1004191.
75. Rizvi S, Raza ST, Mahdi F. Telomere length variations in aging and age-related diseases. Curr Aging Sci. 2014;7(3):161-167. doi: 10.2174/1874609808666150122153151.
76. Corfdir C, Pignon B, Szoke A, Schurhoff F. [Accelerated telomere erosion in schizophrenia: A literature review]. Encephale.
2021 Aug;47(4):369-375. doi: 10.1016/j.encep.2020.12.001.
77. Kimura M, Cherkas LF, Kato BS, Demissie S, Hjelmborg JB, Brimacombe M, Cupples A, Hunkin JL, Gardner JP, Lu X, et al. Offspring's leukocyte telomere length, paternal age, and telomere elongation in sperm. PLoS Genet. 2008 Feb;4(2):e37. doi: 10.1371/journal.pgen.0040037.
78. Prescott J, Du M, Wong JY, Han J, De Vivo I. Paternal age at birth is associated with offspring leukocyte telomere length in the nurses' health study. Hum Reprod. 2012 Dec;27(12):3622-3631. doi: 10.1093/humrep/des314.
