Changes in Levels of Phosphorus Metabolites
in Temporal Lobes of Drug-Naive
Schizophrenic Patients
Hiroshi Fukuzako, M.D., Tsuyoshi Fukuzako, M.D., Tomo Hashiguchi, M.D.,
Satoshi Kodama, M.D., Morikuni Takigawa, M.D., and Toshiro Fujimoto, M.D.
Objective: The authors examined phospholipids and high-energy phosphorus metabo-
lism in the temporal lobes of drug-naive schizophrenic patients. Method: In vivo 31P mag-
netic resonance spectroscopy was performed on 17 first-episode, drug-naive schizo-
phrenic patients and 17 age- and gender-matched healthy subjects. Results: Patients
showed higher levels of phosphodiesters and lower levels of phosphomonoesters than the
comparison group. Phosphocreatine levels were increased in the left temporal lobes of pa-
tients. Conclusions: The results suggest disturbed membrane phospholipid metabolism in
both temporal lobes and decreased energy demands in the left temporal lobes of drug-na-
ive schizophrenic patients.
(Am J Psychiatry 1999; 156:1205 1208)
lipid metabolism has been proposed as a neurodevel-
In vivo 31P magnetic resonance spectroscopy (MRS)
opmental pathogenesis of schizophrenia (10). Under
allows direct measurement of membrane phospholip-
this hypothesis, MRS in the drug-naive state is likely to
ids and high-energy phosphate metabolism in the brain
give more useful information for investigating patho-
(1). With 31P MRS, increased levels of phosphodiesters
physiologic mechanisms of schizophrenia than studies
and decreased levels of phosphomonoesters have been
of medicated patients. However, no report of MRS has
observed in the frontal lobes of drug-naive schizo-
described metabolite changes in the temporal lobes of
phrenic patients (2, 3). Increased ² -phosphates of ATP
drug-naive schizophrenic patients. In this study, we re-
(² -ATP) and decreased inorganic orthophosphate also
port metabolite changes observed in the temporal
have been reported (2). When 31P MRS studies have
lobes of schizophrenic patients during initial psychotic
included chronically medicated schizophrenic patients,
episodes while they were still drug naive.
findings have been inconsistent: while most investiga-
tors have found decreased phosphomonoesters or in-
creased phosphodiesters or both (4 6), a recent study
METHOD
demonstrated a decrease in phosphodiester level in
schizophrenic patients (7). These inconsistencies may
Seventeen first-episode, drug-naive Japanese patients (10 men and
be caused by differences in patient characteristics such
seven women; mean age=23.1 years) who met DSM-III-R criteria for
as chronicity of illness, diagnostic subtype, and medi-
schizophrenia and were right-handed according to the Edinburgh
cation status, as well as the MRS method employed.
Handedness Inventory were recruited from the outpatient clinics of
31
Fujimoto Hospital and Kagoshima University Hospital from 1991 to
P MRS specifically investigating the temporal lobes
1996. One neuropsychiatrist evaluated the patients with the Oxford
also has yielded contradictory results in medicated
version of the Brief Psychiatric Rating Scale (BPRS). All the patients
schizophrenic patients (5, 8, 9). Disturbed phospho-
were treated in the two institutions, and their diagnosis was recon-
firmed 1 year after the first scan. Patients had been ill for 6.6 months
Received July 13, 1998; revision received Feb. 5, 1999; accepted
(SD=6.2). Seventeen age- and gender-matched healthy subjects
Feb. 9, 1999. From the Department of Neuropsychiatry, Faculty of
(mean age=22.5 years) served as a comparison group. All subjects
Medicine, Kagoshima University; and the South Japan Health
gave written informed consent for participation in the study. None
Science Center, Miyazaki. Address reprint requests to Dr. Hiroshi
had a recent history of alcohol or drug abuse.
Fukuzako, Department of Neuropsychiatry, Faculty of Medicine,
The method of MRS data acquisition and processing has been de-
Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8520,
scribed in our previous report (4). Spectroscopy was performed with
Japan; fukuzako@med4.kufm.kagoshima-u.ac.jp (e-mail).
a Siemens-Asahi Meditec MR system with a magnetic field strength
Supported by grants from the Ministry of Science, Culture, and
of 2.0 T. A circular polarizing head coil was tuned to 84.5 MHz for
Education (05770735 and 06770764) and the National Center of
proton imaging and to 34.2 MHz for in vivo multivoxel 31P MRS
Psychiatry and Neurology of the Ministry of Health and Welfare
(two-dimensional chemical shift imaging). The field of view was 24
(3A-5) of Japan (Dr. H. Fukuzako).
cm with an 8× 8 data matrix and a 4-cm section thickness. Spectra
Am J Psychiatry 156:8, August 1999 1205
CHANGES IN PHOSPHORUS METABOLITES
FIGURE 1. T1-Weighted MR Image Showing Placement of the FIGURE 2. Typical in Vivo 31P MR Spectrum (upper panel) and
Volume of Interest in a Patient With Schizophreniaa Lorentzian Curve-Fitted Spectra (lower panel) for Each Metab-
olitea
a
Spectra are obtained from the two volumes of interest (left: 6+10;
right: 3+7).
were obtained from the two volumes of interest, each consisting of
72 ml (figure 1). The TR was 2 seconds, and the TE was 1.72 msec.
Twelve measurements were obtained for each spectrum. Data were
processed with Fourier transformation and exponential multiplica-
tion (16 Hz) and then phase-corrected. Spectral peaks were ob-
tained for phosphomonoesters, inorganic orthophosphate, phos-
phodiesters, phosphocreatine, and Å‚ -, Ä… -, and ² -ATP. Spectra were
-10
10 0 -20
quantified according to peak-area measurements. An automated
Chemical Shift (ppm)
baseline correction technique removed the distortion in the baseline
of the spectra (11). Peak measures such as height, position, and
a
PME=phosphomonoesters, Pi=inorganic orthophosphate, PDE=
width were obtained by a Lorentzian curve-fitting procedure (figure
phosphodiesters, PCr=phosphocreatine.
2). For each spectrum, the integrated areas of the seven metabolites
were measured, and mole percentages of total phosphorus signal
were calculated.
phomonoesters (N=17; left: Ä =0.17, p=0.34; right: Ä =
Repeated measures analysis of variance (ANOVA), with a be-
0.10, p=0.59), phosphodiesters (N=17; left: Ä =0.04, p=
tween-subject factor of diagnosis and a within-subject factor of side,
was applied to the mole percentage of the seven metabolites. 0.84; right: Ä =0.04, p=0.84), or phosphocreatine (N=
17; left: Ä = 0.07 p=0.68; right: Ä = 0.19, p=0.30).
RESULTS
DISCUSSION
Significant effects of diagnosis were seen for phospho-
monoesters and phosphodiesters, with increased levels In this study, 31P MRS detected an elevation of
of phosphodiesters and decreased levels of phospho- phosphodiesters and reduction of phosphomonoesters
monoesters in both temporal lobes (table 1). A signifi- in the temporal lobes of drug-naive schizophrenic pa-
cant diagnosis-by-side interaction was observed for tients compared with healthy subjects. These results
phosphocreatine, with higher values on the left than on are consistent with previous observations reported in
the right side in schizophrenic patients relative to the prefrontal cortex of schizophrenic patients (2, 3).
healthy subjects. MR imaging revealed no obvious ab- Pettegrew et al. (2) have speculated that decreased
normalities in patients or healthy subjects. The mean phosphomonoesters and increased phosphodiesters in
BPRS score was 35.6 (SD=12.7). Kendall s rank corre- the frontal lobes of schizophrenic patients may reflect
lation coefficient revealed no significant correlation decreased synthesis and increased breakdown of mem-
between the total BPRS score and percentages of phos- brane phospholipids. However, the interpretation of
1206 Am J Psychiatry 156:8, August 1999
PCr
PDE
Pi
-ATP
Å‚
Ä…
-ATP
PME
²
-ATP
FUKUZAKO, FUKUZAKO, HASHIGUCHI, ET AL.
TABLE 1. Concentrations of Phosphorus Metabolites in the Temporal Lobes of Drug-Naive Schizophrenic Patients and Normal
Comparison Subjects
Percent of Total Phosphorus Signal
Schizophrenic Comparison
Patients (N=17) Subjects (N=17) ANOVA
Metabolite and Hemisphere Mean SD Mean SD Source F (df=1, 32) p
Phosphomonoesters
Left 9.6 1.6 10.6 1.3 Diagnosis 5.06 0.03
Right 9.5 1.5 10.4 1.7 Side 0.19 0.67
Diagnosis by side 0.01 0.98
Inorganic orthophosphate
Left 5.7 1.2 6.0 1.2 Diagnosis 2.01 0.17
Right 5.4 1.2 6.0 1.4 Side 0.30 0.59
Diagnosis by side 0.32 0.58
Phosphodiesters
Left 41.5 3.3 38.3 1.9 Diagnosis 13.39 <0.01
Right 41.0 2.9 38.0 3.2 Side 0.43 0.52
Diagnosis by side 0.05 0.82
Phosphocreatine
Left 11.8 1.4 10.7 1.1 Diagnosis 1.27 0.27
Right 10.7 1.0 11.0 1.7 Side 1.62 0.21
Diagnosis by side 4.57 0.04
² -ATP
Left 10.0 1.1 10.9 1.4 Diagnosis 3.62 0.07
Right 10.2 1.2 10.5 1.3 Side 0.12 0.73
Diagnosis by side 0.88 0.35
Å‚ -ATP
Left 9.2 1.7 10.7 1.6 Diagnosis 2.95 0.10
Right 10.7 1.9 10.8 1.6 Side 3.85 0.06
Diagnosis by side 3.78 0.06
Ä… -ATP
Left 12.4 1.7 12.9 1.3 Diagnosis 1.83 0.19
Right 12.6 1.9 13.3 2.3 Side 0.52 0.48
Diagnosis by side 0.04 0.84
the findings is not easy, as they previously suggested. schizophrenic patients and healthy subjects (15). Al-
Decreased phosphomonoesters resonance in this study though definitive determination of the origins of de-
may imply a reduction in freely mobile phospho- creased phosphomonoesters and increased phosphodi-
monoesters (phosphocholine, phosphoethanolamine) esters is difficult, the disturbed membrane phospholipid
or less mobile molecules (including phosphorylated metabolism may not be restricted to the frontal lobe in
the manner of the gray matter volume reduction ob-
proteins) or both (1). Reduced synthesis of membrane
phospholipids is one of these possibilities. The phos- served in schizophrenic patients (16).
phodiester resonance in 31P MRS in vivo is believed to
The level of phosphocreatine was increased in the
be derived from mobile phosphodiester moieties (small
left temporal lobe in schizophrenic patients. Phospho-
membrane phospholipid structures such as micelles
creatine is known to be rapidly transformed to ATP
and vesicles) and breakdown products (1, 12). Phos- when ATP is consumed by neuronal activity (17). An
phodiesters are more concentrated in white than in the increased percentage of phosphocreatine may imply re-
gray matter (13). Therefore, the increase in phosphod- duced ATP utilization in the left temporal lobe of drug-
iesters could have resulted from increased mobile naive schizophrenic patients. This asymmetric abnor-
phosphodiester moieties including glycerophospho- mality in energy metabolism agrees with left-sided
choline and glycerophosphoethanolamine, as well as functional impairments observed in the temporal lobes
small membrane phospholipid structures, or it could of schizophrenic patients with single photon emission
have been a reflection of a decreased ratio of gray-to- computed tomography (18).
white matter volume in the volume of interest (14).
Several methodologic limitations need to be ad-
Which phosphodiester components contribute to the
dressed. The phosphorus metabolites were analyzed
elevation of phosphodiester resonance could be dis- without correction for multiple comparison because of
tinguished by using 1H-decoupled 31P MRS. A pre- the small group size and the exploratory nature of this
liminary study has shown that membrane or mobile
study, in spite of the increased risk of a type I error.
phospholipids are increased in the frontal lobes of
Our curve-fitting method may have a drawback in that
chronically medicated schizophrenic patients (6). On all seven metabolites were modeled as single spectral
the other hand, elevations of glycerophosphocholine peaks, which could influence the results. Other meth-
and glycerophosphoethanolamine concentrations have odologic limitations inherent in MRS procedures have
been demonstrated in the parietal lobes of young med- been outlined in previous reports (8, 19). Further stud-
icated schizophrenic patients compared with elderly ies, in a larger group and with more sophisticated in
Am J Psychiatry 156:8, August 1999 1207
CHANGES IN PHOSPHORUS METABOLITES
spectroscopy in schizophrenia: correlation between mem-
vivo MRS techniques, will be needed to confirm our
brane phospholipid metabolism in the temporal lobe and pos-
preliminary findings.
itive symptoms. Prog Neuropsychopharmacol Biol Psychiatry
1996; 20:629 640
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