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Give us this day our daily bread….

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Bagels, Biscuits, Baguettes, and Schizophrenia

April 4, 2018p

William W. Eaton

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Outline

• The puzzle of Schizophrenia

• Wheat and Schizophrenia• Wheat and Schizophrenia

• Leaky gut and Gluten Sensitivity

• Results from R34

• Design of Double Blind RCT

S h f M h i• Search for Mechanisms

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The Puzzle of Schizophrenia

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Skepticism about sociocultural factors

Writing … a review of studies of the social etiology of schizophrenia is like talking with the relatives of the

Outlook from 30-50 years ago

sc op e a s e ta g t t e e at es o t edeceased after returning from the funeral. Other than some platitudes, there is little that can be suggested that would remedy, alleviate, or eliminate the trouble. Mishler and Scotch, Psychiatry, 1963

Skepticism about genetics

5 © 2009, Johns Hopkins University. All rights reserved.

In short, the extent of the genetic component, if any, in DSM-III schizophrenia remains unresolved. Pope et al, American Journal of Psychiatry, June 1982.

Descriptive versus mechanistic diagnosis

Jerry Morris’ 7th use of epidemiology

6 From Leboyer et al, BMC Medicine, 2016

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Odds Ratios and 95% Confidence Intervals in 8 studies Author Date Sample

Ross et al. 1950 1608

Arthritis and Schizophrenia

Pilkington 1955 318

Baldwin 1980 7718

Mohamed et al. 1982 162

Allebeck et al. 1985 11342

Oken & Schulzer 1999 229972

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Oken & Schulzer 1999 1984

Mors et al. 1999 20495

.05 0.1 0.2 0.5 1.0

2.0 5.0

Source: Eaton and Chen, 2004

Schizophrenia: Autoimmune Disease?

• Clinical findings that suggest Schizophrenia might be some sort of autoimmune disease

– Relapsing course with unpredictable episodes

– Autoantibodies can produce psychosis (SLE)

– Immunologic abnormalities (Ganguli et al, 1987, 1993)

Decreased IL 2

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• Decreased IL 2

• Increased IL 2 receptors

• Increased IL 6

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1985

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Wheat and Schizophrenia

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Source: Main Line Times, Thursday, November 14, 1991

1986

“It was fun.”

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• Gluten is a protein composite found in foods containing wheat

What is Gluten?

found in foods containing wheat, barley and rye

• Gives elasticity to dough, helping it to rise and keep its shape

• The composite is gliadin and glutenin (gliadin is alcohol soluble g (gand glutenin is insoluble in dilute acids).

• Gluten is fairly indigestible in most people

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CHFIQPQQPFPQQPQQSFPQQQPSLIKEnter this sequence of amino acids:

NCBI: National Center for Biotechnology Information

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During World War II, as wheat consumption went

Wheat and Schizophrenia

wheat consumption went down in Scandinavia, admissions for schizophrenia went down; as wheat consumption in the United States went up, admissions for schizophrenia went up.

Dohan, Acta, 1966

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Schizophrenia is almost non-existent

Wheat and schizophrenia

existent in populations consuming little or no grain

Source: Dohan, Harper, et al. Is schizophrenia rare if grain is rare? Biological Psychiatry 1984; 19: 385-399.

1973

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14 persons with schizophre

i ith 6nia with 6 weeks of gluten withdrawal, followed by four weeks of addition

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of gluten(Singh and Kay, 1976)

Singh and Kay, 1976

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Author Date Sample Results

Dohan 1969 102 62% discharged versus 32%

Dohan/Grasberger 1973 115 37% to open ward versus 16%

Clinical Trials of Withdrawal of Gluten Withdrawal in Schizophrenia

Singh and Kay  1976 14 Improvement on 30/39 measures

Rice 1978 16 Two improved

Potkin 1981 8 No change in functioning

Storms 1982 26 No change in functioning

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Osborne 1982 4 No change in functioning

Vlissides 1986 24 Improvement in 5/12 measures

Kelly/Eaton 2016 16 Improvement in SANS

Case study of Schizophrenia, celiac disease, and hypofrontality

Before gluten-free diet hypofrontality is present

Hypofrontality not present six months after start of gluten-free diet

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Source: De Santis et al. Schizophrenic symptoms and SPECT abnormalities in a coeliac patient: regression after a gluten-free diet. Journal of Internal Medicine 1997; 242:421-423.

start of gluten free diet

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William W. Eaton, Lian-yu Chen, Curtis Dohan, Jr., Deanna Kelly, Nicola Cascella

Prior Celiac Disease raises risk for Schizophrenia

Data from linked Danish National Case Registers Prevalence/1,000 Relative Risk*

Cases Controls Univariate Adjusted Celiac 1.5 0.5 3.2 3.2 (1.8–5.9) Chron’s Disease 4.5 3.4 1.3 1.4 (1.0–1.9) Ulcerative Colitis 6.2 4.7 1.3 1.4 (1.0–1.8)

24Continued

Source: Eaton et al, BMJ, 2004

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Autoimmune Diseases and risk for Schizophrenia in Denmark

25Source: Eaton et al, AJP, 2006

Autoimmune Diseases and risk for Schizophrenia in Denmark

45% increased i k frisk for

schizophreniafor persons with history of any autoimmune disease

26Source: Eaton et al, AJP, 2006

disease

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• “… anti-endomysial and antigliadin antibodies are noninvasive and nonexpensive tests and should be

Screening for Celiac Disease?

pperformed to screen patients with schizophrenic symptoms, in order to exclude coeliac disease as a potentially treatable condition.”

• De Santis et al, JIG, 1997)

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Leaky gut, Celiac Disease, and Gluten Sensitivity

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Lancet, 2000

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ANYAS, 2012

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Non-celiac gluten sensitivity (NCGS) now y ( )recognized as one of many gluten-related diseases. Presumed to involve innate immunity, not adaptive immunity .

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Tight junctions are important for immune function.PNAS, 2009

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Prehaptoglobin 2 is now recognized as a candidate gene for schizophreniaWell waddya know?

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Schizophrenia and Gliadin: Defining a Subgroup

• Gliadin is a protein found in wheat, barley and rye which may trigger different types of immune reactionsy gg yp

• An immune reaction to gliadin can occur in 3 forms: Celiac Disease, Non-Celiac Gluten Sensitivity (Gluten Sensitivity) and wheat allergy

• Gluten Sensitivity is a different type of immune response than Celiac Disease

• No prior work has examined effects of gluten-free diet in a subgroup having gluten sensitivity

R34 Developmental Study

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Author Year N patients % positive N healthy % positive Odds ratio

Anti‐gliadin IgA

Reichelt 1995 48 19% 13 0 6.3

Dickerson 2010 NA NA NA NA 2.0/2.7

Cascella 2011 1401 23% 900 3 1 9 3

IgA and IgG Antigliadin Antibodies in schizophrenia and controls

Cascella 2011 1401 23% 900 3.1 9.3

Sidhom 2012 47 4.5% 41 10.5% 0.4

Jin 2012 473 27% 41 10.5% 1.7

Pooled IgA OR 2.57

Anti‐gliadin IgG

Dickerson 2010 NA NA NA NA 5.5/6.2

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Cascella 2011 1401 1.4% 900 3.3% 0.4

Sidhom 2012 47 59% 41 23.9% 4.6

Jin 2012 419 17.9% 478 14.2% 1.3

Okusaga 2013 950 21.9% 1000 10.0 2.13

Lachance and McKenzie, Schizophrenia Research 2013                                              Pooled IgG OR 2.31

IgG AGA levels in 160 persons with schizophrenia and 80 healthy controlsSamples from Baltimore

AGA IgGAGA IgGmore important than AGA IgA

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Randomized Double‐Blind Feasibility Study of a Gluten‐Free Diet in People with Schizophrenia and Elevated AntigliadinAntibodies (AGA IgG)Poster to be presented at the Schizophrenia International Research Society Congress 

lApril 4‐8, 2018

Deanna L. Kelly1, Haley Demyanovich1, Katrina Rodriguez2, Daniela Cihakova2, Monica V. Talor2, James Gold1, Sharon August1,    Robert W. Buchanan1, Stephanie M. Feldman1, Fang Liu1, William T. Carpenter, Jr.1, William W. Eaton2

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1Maryland Psychiatric Research Center, University of Maryland School of Medicine;  2Johns Hopkins University

Randomized Double-Blind Gluten-Free Diet Study

• Double-blind randomized gluten-free inpatient feasibility study for 5 weeks

• All participants received a gluten free diet – Protein shake daily with 10 gm of Gluten flour or 10 gm of Rice flour

• Participants discharged on gluten free diet evaluated for 8Participants discharged on gluten free diet, evaluated for 8 weeks

• First study in schizophrenia to select subjects based on antibodies, but not powered to find an effect

• Clinical Trials.gov NCT#01927276 (NIMH funded R34)

Kelly D, Eaton WW, et al. In preparation, 2018

Slide from D. Kelly, CPNP

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Inclusion/Exclusion CriteriaInclusion• DSM-IV/DSM 5 diagnosis of

schizophrenia or schizoaffective

Exclusion• Already on gluten free diets

P iti it t tip

disorder • Positive for gliadin antibodies

(IgG ≥ 20 U)• Age 18- 64 years• BPRS total score >29• Same antipsychotic for at least

4 weeks

• Positivity to tissue transglutaminase (tTg) antibodies or known history of Celiac Disease

• Pregnant or lactating females

• Meets DSM-5 criteria for alcohol or substance use disorder (other than nicotine) within last month4 weeks

• Ability to consent determined by a score of ≥ 10 on the Evaluation to Sign Consent

than nicotine) within last month

• Gluten ataxia (Brief Ataxia Rating Scale)

Slide from D. Kelly, CPNP

375 screened for Antigliadin Antibodies

26 completed eligibility

100/370 positive for AGA (27%)64 recruited for inpatient study

5 excluded for tTG positivity

PARTICIPANT FLOW 

DIAGRAM GLUTEN‐FREE DIET STUDY 26 completed eligibility

screening for inpatient study

19 randomized

Gluten Free Diet (N=7)

Gluten Containing Diet (N=9)

2 excluded <20 U AGA IgG

1 excluded: <20 U AGA IgG

2 Withdrawals:1 Beginning of week 4: Personal choice1 End of Week 4: Housing Reasons

N=7 completed

N=7 completed

8 Post Discharge Randomized Open-Label Follow-Up of

Gluten Free Diet

N=5 assessed at 8 weeks

N=3 assessed at 8 weeks

Slide from D. Kelly, CPNP

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Demographic and Clinical InformationGluten‐Containing 

Diet (N=9)

Gluten‐Free Diet (N=7) Statistics

Mean age (Years) 42.0 ± 14.6 32.5 ± 9.7 p=0.22

Sex (Male) N=5 (56%) N=4 (57%) p=1.00

Race (African American) N=7 (78%) N=5 (71%) p=1.00

Age of Illness onset (Years) 16.9 ± 3.4 18.2 ± 2.4 p=0.61

Level of Education (Years) 11.8 ± 1.3 12.4 ± 2.1 p=0.29

Smokers N=5 (56%) N=6 (86%) p=0.20

Body Mass Index (kg/m2) 28.5 ± 4.7 31.4 ± 8.9 p=0.71

Baseline AGA IgG (U) 55.8 ± 28.6 43.8 ± 12.2 p=0.56

Baseline AGA IgA (U) 23.6 ± 21.1 32.9 ± 28.3 p=0.49

Antipsychotics

First‐Generation Antipsychotics (FGA)

Second‐Generation Antipsychotics (SGA)

Clozapine

N=2 (22%)

N=2 (22%)

N=2 (22%)

N=2 (29%)

N=2(29%)

N=1 (14%)

p=0.96

Clozapine

SGA + FGA

N 2 (22%)

N=3 (33%)

N 1 (14%)

N=2 (29%)

Antidepressants

Anticholinergic medications

N=6 (67%)

N=7 (78%)

N=3 (43%)

N=6 (86%)

p=0.34

p=0.69

Meals per day with gluten 1.7 ± 1.1 2.1 ± 1.2 p=0.52

Gastrointestinal Disorder

Dermatologic Disorder

N=4 (44%)

N=1 (11%)

N=4 (57%) 

N=3 (43%)

p=0.53

P=0.13

Kelly D, Eaton WW, et al.  In preparation, 2018 Slide from D. Kelly, CPNP

ES=‐0 34

AGA IgG

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6016% Decrease

34% Decrease

0.34

34% Decrease

16% Decrease20

30

40

50

Kelly D, Eaton WW, et al. In preparation, Slide from D. Kelly, CPNP88

0

10

Gluten‐Containing Diet (N=9) Gluten‐Free Diet (N=7)

Baseline Endpoint

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Mean AGA IgG by Haptoglobin Gene Polymorphism

30

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Mean AGA IgG (U) in schizophrenia group

N=47

N=30

10

15

20

25

30

N=23

> 20 U considered elevated

0

5

Genotype 1‐1 Genotype 1‐2 Genotype 2‐2

Baseline 

Gluten‐

Containing 

Diet (N=9)

Endpoint 

Gluten‐

Containing 

Diet (N=9)

Baseline 

Gluten‐Free 

Diet 

(N=7)

Endpoint 

Gluten‐Free 

Diet 

(N=7)

Treatment Effects

Total BPRS 37.4 ± 6.2 31.1 ± 5.5  35.9 ± 5.4 31.6 ± 6.7 ES= 0.40                F=0.05, 

df=10.7, p=0.83  

Positive 

symptoms

7.3 ± 1.9 7.0 ± 2.3 5.9 ± 1.1 6.4 ± 1.6 ES= 0.39               F=0.22, 

df=14.1, p=0.64  

Calgary 

Depression 

Rating Scale

4.8 ± 3.2 1.9 ± 1.6 2.4 ± 2.5 1.6 ± 1.3 ES= 0.13             F=0.00, 

df=1,13.7, p=0.95

CGI 3.9 ± 0.6 3.9 ± 0.4 4.1 ± 0.7 3.6 ± 0.8 ES= ‐0.75            F=2.36, 

df=1,13.1, p=0.15

F=4.76, df=53.2, p=0.0023   

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Tx x Time

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No change in Simpson Angus0.4

0.5

0.6

0.7

0.8 MATRICS Consensus Cognitive BatteryEffect Sizes

No change in Simpson Angus Scale  F=0.3, df=1,14, p=0.59; 

Barnes Akathisia Scale F=2.92, 1,14, p=1.09, or in BMI F=0.10, 1,12.6, p=0.76

‐0.3

‐0.2

‐0.1

0

0.1

0.2

0.3

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0.3

Change in SANS Score in double blind RCTPersons with schizophrenia and IgG AGA

7 gluten free and 9 gluten containing diet

First difference week 2 (t=2.37, df=1,12.7, p=0.03); The total score is driven by robust effects in avolition (d=0.5), blunted affect (d=1.1), and alogia (d=0.7).   Eaton, Kelly, unpublished data

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Correlation of AGA IgG and TNF-ᾳIn 100 persons with schizophrenia

Proinflammatory Cytokines and AGA IgG

In 100 persons with schizophreniaR=0.42

Correlation of AGA IgG and IL-1β

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In 100 persons with schizophreniaR=0.51

Kelly et al, Brain, Behavior and Immunity, 2018

Initial Zonulin Work• Mean zonulin levels in

schizophrenia were 2.38 mg/dL(SD 1.23 mg/dL)

• Zonulin or cytokines do notp = .024*

2.5

Effect of IL-1β  vs. zonulin-IL-1β  Interaction on BPRS

score Zonulin or cytokines do not relate to psychiatric symptoms

• Zonulin with cytokines leads to prediction of total BPRS

• For example, zonulininteracts with IL-1β on:

– BPRS total (p=.024),

p = .014*p = .000*

p = .709p = .113

p = .027*

0

0.5

1

1.5

2

Sta

nd

ard

co

effic

ien

ts (

bet

a) IL-1β

Zon*IL-1β

(p ),

– BPRS hostility (p<.0001)

– BPRS anxiety/depression (p=.027)

Kelly D, et al. Presented at the American College of Neuropsychopharmacology (ACNP), December 2017

p = .282 p = .131 p = .642p = .131 p = .490p = .430

-0.5

0

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Design of Double Blind Randomized Controlled Trial

2017

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Full-scale trial, Funded

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Identify persons with schizophrenia who are 18-45 from EPIC

Send Recruitment Letter to home address

Meet before or after next therapy sessionE l i h

Screening Procedures

Explain researchEvaluate Ability to sign ConsentObtain consentDraw blood

Assay for IgG AGA and IgG tTG

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Positive for IgG tTG (celiac disease)refer to therapist and recommend contact with physician

Positive for IgG AGAsend information to Maryland Psychiatric Research Center

Negative for IgG AGA and IgG tTGsend letter stating negative results

MPRC Contact Potential Recruit JHU 500 300

350 - 150+ AGA IgG Assay 90+ 210 -

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Screening 800 to recruit 60 for inpatient trial

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140 Recruit for visit 100 decline to visit

120 SCID positive 20 SCID negative

40 Exclusion + 80 Inclusion +

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40 Exclusion + 80 Inclusion +

20 decline 60 Enter trial

30 Treatment 30 Control

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Confirmation of diagnosis with SCIDScreening for exclusion criteria60 persons starting, ~50 completing the trialGluten free diet for five weeks

Treatment Group: protein shake with rice (25 gms)

Brief Overview of MPRC Double Blind RCT

Control Group: protein shake with gluten (25 gms)Weekly Assessments

SANS BPRS Gastrointestinal Symptom Rating ScaleAGA

Baseline/endpoint Assessments

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pMatrics Cognitive Battery Proinflammatory Immune MarkersGut permeability: Zonulin, ASCANeuroimaging n = 30

Followup for two months post release

Search for Mechanisms

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It is not just the gut that is leaky!

Serological casein and gluten IgGcorrelate with CSF casein and gluten IgG in

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g gschizophrenia

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Psychosomatic Medicine, 2016

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Kynurenine higher in persons with schizophrenia in top 10% of IgG values:

Kynurenine/Tryptophan ratio higher in persons

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Kynurenine/Tryptophan ratio higher in persons with schizophrenia in top 10% of IgG values:

The microbiome may be involved

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Gut Permeability and Mimicry of the Glutamate Ionotropic Receptor NMDA type Subunit Associated with protein 1 (GRINA1) as Potential Mechanisms Related to a Subgroup of People with Schizophrenia with elevated AntigliadinAntibodies (AGA IgG)Running title: GRINA, ASCA and Gliadin Antibodies in Schizophrenia

Daniela Čiháková1, 2 et al Submitted to Biological Psychiatry

•160 persons with schizophrenia and 80 healthy controls

Antibodies to bacteria associated with Leaky Gut

•160 persons with schizophrenia and 80 healthy controls

•association between AGA IgG and ASCA IgG in schizophrenia (p=0.05) suggests permeability of the gut and the blood brain barrier(ASCA = Anti‐Saccharomyces Cerevisiae antibodies, known to be associated with leaky gut)

AGA I G l t d t GRINA1 i ith hi h i GRINA1 i

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•AGA IgG related to GRINA1 in persons with schizophrenia: GRINA1 is a glutamate receptor similar in structure to gliadin 33‐mer segment

•mimicry through the presence of cross‐reactivity between gliadin and GRINA1 may contribute to inflammation or disruption of glutamate process

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Magnetic Resonance Spectroscopy in 33 persons with schizophrenia shows that myoinositol in the anterior cingulatecortex is correlated with serum AGA IgG (r=0.47, p < 0.007)

Implications

Identification of a subtype of schizophrenia might lead to better understanding of etiologyg gy

The gliadin-reactive subtype might be affecting as many as 1,000,000 persons

Removal of gluten from the diet is not easy but not i

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expensive

Gluten withdrawal would be the first new form of treatment for schizophrenia in half a century