RSJD Dr. Amino Gondohutomo, Central Java 347 Brigjend. Sudiarto Street, Semarang City, 50611, Indonesia
RSJD Dr. Amino Gondohutomo, Central Java 347 Brigjend. Sudiarto Street, Semarang City, 50611, Indonesia
RSJD Dr. Amino Gondohutomo, Central Java 347 Brigjend. Sudiarto Street, Semarang City, 50611, Indonesia
Glutathione Reductase
Innawati Jusuf , Hery Murtantyo Hutomo1*, Sri Woroasih 2, Alifiati Fitrikasari1
1
1
Psychiatry Department, Faculty of Medicine, Diponegoro University
Dekanat Lama Building 1st floor
Dr. Sutomo Street Number 16, Randusari, Semarang City, 50244, Indonesia.
*Correspondence: E-mail: [email protected], Tel. (+62)85357500070
2
RSJD dr. Amino Gondohutomo, Central Java
347 Brigjend. Sudiarto Street, Semarang City, 50611, Indonesia
ABSTRACT
Introduction: Schizophrenia is a severe mental disorder marked by psychiatric syndromes
consist of positive, negative and cognitive disorders. It significantly reduces patient’s quality of
life. Oxidative stress is known to play a role in schizophrenia’s pathophysiologies or hypotheses.
Glutathione (GSH) is the main antioxidant in the brain. In its formation process, Glutathione
Reductase (GR) enzyme is needed. Folic acid is a vitamin that prevents oxidative stress by
blocking hyperhomocysteinemia, a condition that increases free radicals decreases GSH levels.
Aim: This study is held to determine the effect of folic acid as adjuvant therapy on Glutathione
reductase level and PANSS score in chronic schizophrenic patients.
Methods: This research is a double-blind, randomized controlled trial with the pre-test and post-
test design. A total of 72 patients were included in this study, divided into treatment and control
groups. The study gave antipsychotics and 2 mg of folic acid for the treatment group, whereas
the control group got antipsychotics and a placebo. The study was conducted for 3 weeks during
hospitalization. PANSS score and GR level (pg/ml) were measured on the first day and after the
intervention was completed.
Results: In this study, there was a significant increase in glutathione reductase level and a
significant decrease in total PANSS score in both pre-test and post-test amongst the control and
treatment groups (p<0.001). To be precise, there was a significant decrease in general, positive,
and negative PANSS score on both pre and post-test for the control and treatment groups
(p=0.029; p=0.015; p<0.001 respectively).
Conclusion: Folic acid as an adjuvant therapy has an effect on increasing glutathione reductase
level and decreasing PANSS score in chronic schizophrenic patients.
Keywords: chronic schizophrenia, folic acid, glutathione reductase levels, PANSS score
INTRODUCTION
Schizophrenia is a severe mental disorder marked by psychiatric syndromes, such as
positive, negative and cognitive symptoms.[1] The 2018 Basic Health Research (Riskesdas)
[3] It is a condition that arises due to the excessive formation of free radicals such as reactive
oxygen species (ROS) and reactive nitrogen species (RNS), causing an imbalance between the
oxidation process and antioxidant availability.[4] Antioxidants play a role in balancing free
radicals in the body, such as reactive oxygen species (ROS), leading to oxidative stress reduction
Glutathione (GSH) is a major antioxidant in the brain and plays a key role against
oxidative stress. In its formation process, the glutathione reductase (GR) enzyme is needed.[6] In
schizophrenic patients, the GSH level declines as much as 40% in the frontal cortex area and
35% in blood plasma.[9] Studies found that declined GSH level was worsening the Total
Folic acid is a vitamin that prevents oxidative process through a one-carbon cycle
as ROS, and decreases GSH level.[7,8] Therefore, folate deficiency has been identified as a risk
To sum up, hyperhomocysteinemia can decrease the GSH and GR levels, which will
worsen schizophrenia symptoms. On the other hand, folic acid plays a role in preventing
METHODS
This study used a double-blind, randomized controlled trial with a pre-test and post-test
study design. It was conducted at the Dr. Amino Gondohutomo Regional Mental Hospital
Semarang. Blood samples for accessing the GSH level were examined at Central Laboratory
Diponegoro National Teaching Hospital Semarang. Data collection was carried out from January
1 to March 30, 2021. This research had obtained ethical clearance from the Health Research
Ethics Committee of Regional Mental Hospital Dr. Amino Gondohutomo, Central Java Province.
Research subjects were selected using consecutive sampling and must meet the following
inclusion criteria: schizophrenic patients aged 21-50 years old, diagnosed by PPDGJ III, have
suffered for at least two years, are receiving standard hospital treatments (psychotropics with or
hypertension, anemia, diabetes mellitus, cardiovascular disease, alcohol and substance abuse are
excluded. Patients who suddenly refuse to follow procedure (given adjuvant therapy or taking
blood samples) and patients who went home at their request before the study ends are considered
to drop out. After selection, the patient's family is asked whether they are willing to participate in
At first, the subjects were asked for their demographical data. Then after being
randomized using four blocks randomization method, they are divided into two groups, the
control and the treatment group. On the first day of treatment, both groups were assessed using
PANSS score and got their serum GR (Glutathione Reductase) level measured. GR serum was
measured using the Elabscience ELISA Kit. Catalog No. E-EL-H1339 96T. The control group
received standard antipsychotics and a placebo for three weeks. The treatment group received
standard antipsychotics and folic acid as adjuvant as much as 2 mg/day for three weeks. Both
groups were monitored and evaluated for adjuvant side effects and clinical conditions daily. In
the third week, all subjects were assessed for PANSS score and their serum GR (Glutathione
RESULTS
Demographic Characteristics Analysis
This study examines demographic variables including age, gender, occupation, marital status,
education, length of illness, genetic history of mental disorder in the family, body mass index,
smoking, number of hospitalizations. A total of 72 people were included in this study. The
Groups
The differences in glutathione reductase level values between the control and the treatment
Table 2. The Differences in Glutathione Reductase Level Between the Control and the
Treatment Groups
Glutathione reductase Groups
p
(pg/ml) Control Treatment
Pre test 1385.69 ± 948.43 1212.14 ± 907,76 0.362‡
Post test 2287.36 ± 2455.50 6719.75 ± 4712,20 <0.001‡*
Delta 901.67 ± 2169.73 5507.61 ± 4944,30 <0.001‡*
† †
P (pre vs post) 0.078 <0.001 *
‡ †
Note: * Significant (p < 0.05); Mann whitney; Wilcoxon
In this study, the mean GR serum value after intervention in the control group was
2287.36 ± 2455.50 and the treatment group was 6719.75 ± 4712.20 (significantly different,
p<0.001). The glutathione reductase level before and after intervention were significantly
increased in both control and treatment groups, with delta values as much as 901.67 ± 2169.73
The Differences in Total PANSS Score Between the Control and the Treatment Groups
The differences in total PANSS score between the control and the treatment groups was shown
Table 3. Differences in Total PANSS Score Between the Control and the Treatment Groups
Groups
Total PANSS p
Treatment Control
Pre test 83.86 ± 17.27 87.69 ± 14.71 0.314§
Post test 49.14 ± 11.02 64.08 ± 11.79 <0.001§*
Delta 34.72 ± 13.18 23.61 ± 9.56 <0.001§*
P (pre vs post) <0.001¶* <0.001¶*
Note: * Significant (p < 0.05); § Independent t; ¶ Paired t
The mean value of total PANSS score after intervention for the control group was
64.08±11.79 and the treatment group was 49.14 ± 11.02. Statistically, both showed a significant
difference (p<0.001). The mean value of the total PANSS score difference (delta) of the control
and the treatment groups was 23.61 ± 9.56 and 34.72 ± 13.18, respectively. There was a
significant decrease in the total PANSS score from 83.86 ± 17.27 to 49.14 ± 11.02 (p <0.001) in
the treatment group. The control group was also having a significant decreased on the total
The Differences in Positive Symptoms of PANSS Score Between the Control and the
Treatment Groups
The difference in positive PANSS score between the control and the treatment groups was shown
in <table 4>.
Table 4. The difference in positive PANSS score between the control and the treatment
groups
Groups
Positive PANSS p
Treatment Control
Pre test 22.94 ± 4.76 23.56 ± 4.74 0.587§
Post test 12.11 ± 2.96 15.03 ± 2.96 <0.001§*
Delta 10.83 ± 4.12 8.53 ± 3.74 0.015§*
P (pre vs post) <0.001¶* <0.001¶*
Note: * Significant (p < 0.05); Independent t; ¶ Paired t
§
After intervention (post-test), there was a significant decrease in positive PANSS score in
both groups, where the positive PANSS score in the control and treatment groups were 15.03 ±
2.96 and 12.11 ± 2.96 respectively (p<0.001). The mean value of the total PANSS score
difference (delta) of the control was 8.53 ± 3.74, and the treatment groups was 10.83 ± 4.12.
Thus, statistically, both groups showed a significant difference (p=0.015). Table 4 also shows a
significant decrease of positive PANSS score in the treatment group, from 23.56 ± 4.74 to 15.03
± 2.96 (p<0.001).
The Difference in Negative Symptoms of PANSS Score Between the Control and the
Treatment Groups
The difference in the negative PANSS score between the control and the treatment
Table 5. Difference in the negative PANSS score between the control and the treatment
groups
Negative Groups
p
PANSS Treatment Control
Pre test 19.28 ± 5.56 19.11 ± 6.48 0.907§
Post test 10.47 ± 3.65 14.89 ± 5.30 <0.001‡*
Delta -8.81 ± 3.91 4.22 ± 3.13 <0.001‡*
† ¶
p(pre vs post) <0.001 * <0.001 *
Note: * Significant (p < 0.05); § Independent t; ‡ Mann whitney; ¶ Paired t; † Wilcoxon.
The negative PANSS score mean score after intervention (post-test) in the treatment
group was 10.47 ± 3.65, and the control group was 14.89 ± 5.30. Statistically, both showed a
The mean score difference of negative PANSS score (delta) in the treatment was 8.81 ±
3.91, and the control group was 4.22 ± 3.13. Statistically, both showed a significant difference
(p<0.001).
<Table 5> also shows that the treatment group found a significant decrease in the
negative PANSS score, from 19.28 ± 5.56 to 10.47 ± 3.65 (p <0.001). The negative PANSS
score was significantly decreased in the control group, from 19.11 ± 6.48 to 14.89 ± 5.30 (p
<0.001).
The Difference in General Symptoms of PANSS Score Between the Control and the
Treatment Groups
The Difference in General PANSS Score Between the Control and the Treatment Groups was
Table 6. The Difference in General PANSS Score Between the Control and the Treatment
Groups
Groups
General PANSS p
Treatment Control
Pre test 41.64 ± 11.33 45.03 ± 9.46 0.173§
Post test 26.56 ± 7.79 34.17 ± 6.78 <0.001§*
Delta 15.08 ± 9.42 10,86 ± 8.42 0.029‡*
P (pre vs post) <0.001¶* <0.001¶*
Note: * Significant (p < 0.05); § Independent t; ‡ Mann whitney; ¶ Paired t.
After the intervention (post-test), there was a decrease in the general PANSS score for
both groups, where the general PANSS score in the treatment group was 26.56 ± 7.79 and in the
control group was 34.17 ± 6.78. Thus, based on the statistical test, the difference in general
PANSS score after the intervention between the two groups showed significant results (p<0.001).
The mean value of the general PANSS score difference (delta) of the control was 10.86 ±
8.42 and the treatment group was 15.08 ± 9.42. Statistically, both showed a significant difference
(p=0.029).
<Table 6> also shows a significant decrease in the general PANSS score for the
treatment group, from 41.64 ± 11.33 to 26.56 ± 7.79 (p <0.001). There was a significant decrease
in the general PANSS score in the control group, from 45.03 ± 9.46 to 34.17 ± 6.78 (p <0.001).
DISCUSSION
In this study, the mean age of all subjects is 33.78 ± 7.70 years. This result is in
prevalence is high at the age range of 30 - 40 years old in both males and females.[12]
The research subjects in this study were dominated by males (69.4%). This result is
consistent with previous epidemiological studies showing that schizophrenia is more common in
men. Several studies showed a difference in schizophrenia symptoms between men and women.
They observed more severe negative symptoms in men compared to women. However, another
study found that the difference in symptoms between women and men was not significantly
different. [13,14]
Most subjects in this study were unemployed (61.1%). This result is in line with another
study conducted by Mark S. Ezeme (2016) on 172 schizophrenic patients in Nigeria, where more
Based on the marital status, the majority of the research subjects were single (50%), and
as many as 13.9% experienced a divorce. This result is similar to a study by Zargar W. et al.
The subjects’ education level was dominated by junior high and high school graduates, as
much as 31.9%. This result is in accordance with previous studies in which high school
The length of illness in this study was 2-21 years, with a mean value as much as 4.67 ±
2.97 years. Another study was stated that the earlier onset of the illness, meaning a longer
duration of illness, the patient's output will decrease, with the dominant symptoms that arise are
In the genetic variables, most research subjects didn’t have a genetic history of mental
disorders in the family (86.1%). This result is not in accordance with previous research. In their
research, Mao Sheng Ran et al. (2017) shows that a family history of mental disorders, especially
[18]
This study is dominated by normal BMI, as much as 75%. This result isn’t in line with
previous research, which states that schizophrenic women suffer more from obesity, which may
Most research subjects (69.4%) are smoking. This study is similar to previous studies,
which stated that 62% of schizophrenic patients were smokers. One hypothesis that is plausible
The average number of hospitalizations in this study was 3.40 ± 1.96. This result is in
line with previous studies, stating that the longer onset of illness, the more hospitalizations were
This study aligns with the previous theory, proclaiming that folic acid supplementation as
an adjuvant therapy plays a role in the GSH formation, especially in the one-carbon cycle. GSH
acts as a cellular redox buffer and is a major liver antioxidant. It also functions as a cofactor for
GPx family antioxidant enzymes that degrade H2O2 and alkyl hydroperoxides, yielding GSSG.
In addition, this study is also supported by research conducted by Aleksandrova (2020), stating
that there is a significant relationship between folic acid deficiency in blood with a decrease of
In another study conducted by Joshua L, et al. (2013), which was conducted on chronic
schizophrenia patients, found a significant difference in terms of blood folic acid level between
the control group who received a placebo and the treatment group who received 2 mg of folic
acid and 400 mcg of B12. This folic acid level increment was starting at week 2.[21]
The Differences in Total PANSS Score Before and After Folic Acid Adjuvant Therapy
The study result obtained at Amino Gondohutomo Regional Mental Hospital regarding
the total PANSS score are in accordance with the research conducted by Xueqin Song, et al
(2014), which stated that folic acid supplementation could significantly reduce the total PANSS
score (p = 0.038). This result is also aligned with Nucifora's (2017) research, where a significant
relationship was found between the declined level of GSH enzyme, an antioxidant, in
schizophrenic patients and an increase in the total PANSS score (p = 0.033).[23] This study
the one-carbon cycle. Homocysteine can also enter the trans-sulfuration pathway leading to the
The Differences in Positive PANSS Score Before and After Folic Acid Adjuvant Therapy
Another study conducted by Nucifora LC et al. (2017), supports the result of this study,
stating that there is a significant relationship between decreased GSH antioxidant enzymes in
schizophrenic patients with an increase in positive PANSS score (p = 0.013).[23] The role of
dysfunction and NMDA receptors disturbance in the prefrontal cortex. Dysfunction of this
neurotransmitter affects the feedback loop of the dopamine neurotransmitter. Positive symptoms
prefrontal cortex.26
The Differences in Negative PANSS Score Before and After Folic Acid Adjuvant Therapy
The study results conducted at the Amino Gondohutomo Regional Mental Hospital
regarding the Negative PANSS score are in accordance with a research done by Xueqin Song, et
al (2014), stating that folic acid supplementation can reduce negative PANSS score (p = 0.034).
[22] K. Langbein also supports this (2017), declared that there is a significant relationship
between decreased plasma glutathione reductase level and an increase in a negative PANSS
score. This occurs because there is a decrease in gray matter density in the orbitofrontal cortex, a
The Differences in General PANSS Score Before and After Folic Acid Adjuvant Therapy
The current study results are supported by JL Roffman, et al (2017), who provided an L-
methylfolate intervention for 12 weeks. This intervention was able to reduce the general PANSS
score (p=0.02). [28] The general PANSS score reduction in the treatment group was lower than
in the control group. Thiress happened maybe due to the effect of folic acid as in the control
group, subjects only received antipsychotic, while in the treatment group, subjects received
CONCLUSION
The use of folic acid as adjuvant therapy improves the psychiatric symptoms of chronic
schizophrenic patients and increases serum glutathione reductase level. The demographic
Gondohutomo Regional Mental Hospital Semarang based on age, gender, occupation, marital
status, education, length of illness, genetic history of mental disorder in the family, body mass
index, smoking habit, number of hospitalizations are varied. However, there was a significant
improvement in the PANSS score between the treatment and control groups, and there was a
significant improvement in serum glutathione reductase levels between the treatment and control
groups.
ACKNOWLEDGEMENTS
“Conceptualization, Hery, Innawati, Sri, Fitri; methodology, Hery, Innawati and Sri; software
Hery; validation, Innawati, Sri, Fitri and Hery; formal analysis, Hery, Innawati and Sri;
investigation, Innawati, Sri , Inawati and Widodo; resources, Hey; data accuracy, Hery; writing-
preparation of original draft, Hery; writing – reviewing and editing, Hery; visualization, Hery;
supervision, Innawati, sri and Fitri; project administration, Innawati and Fitri; fund acquisition,
Innawati and Sri. This work is supported by the Psychiatry Study Program of the Faculty of
Medicine, Diponegoro University. We would like to thank the RSJD dr. Amino Gondohutomo
Semarang and all the participants and their families. The author states there is no conflict of
interest.
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