NZ721414B2 - Mental illness model and mental illness risk assessment test for schizophrenic psychosis - Google Patents

Abstract

Embodiments of the present invention provide methods for diagnosing schizophrenia, schizo- affective disorder and/or psychosis in an individual or predicting risk of the individual developing schizophrenia, schizo-affective disorder or psychosis, by determining values for one or more markers in each of five domains, namely a neurotransmitter domain, an oxidative stress domain, a nutrition-biochemistry domain, a visual processing domain and an auditory processing domain. This model for diagnosis is referred to as the "Mental Illness Risk Assessment Test" (MIRAT). of five domains, namely a neurotransmitter domain, an oxidative stress domain, a nutrition-biochemistry domain, a visual processing domain and an auditory processing domain. This model for diagnosis is referred to as the "Mental Illness Risk Assessment Test" (MIRAT).

Description

MENTAL ILLNESS MODEL AND MENTAL ILLNESS RISK MENT TEST FOR SCHIZOPHRENIC PSYCHOSIS Field of the Invention The present invention relates to a novel set of biomarkers for the sis of, and prediction of susceptibility to, schizophrenia, schizo-affective disorder and psychosis and to methods for the sis of, and prediction of susceptibility to, schizophrenia, schizoaffective disorder and psychosis employing these biomarkers.

Background of the Invention The incidence of mental illness, and its impact on society, appears to be increasing.

Because of the immense personal, social and ial impact of mental illness on sufferers, their families, the ity, the health system and the economy, the ability to accurately diagnose mental illness is of critical importance. Schizophrenia is one of the most disabling mental illnesses, with a lifetime prevalence of about one-percent in the population. Because schizophrenia usually appears early in life and is often chronic, the costs of the disorder are substantial.

Symptoms associated with phrenia are typically characterized as falling into two broad categories--positive and negative (or deficit) symptoms--with a third category, disorganized, recently added. Positive symptoms include delusions and hallucinations. ve symptoms include restricted range and intensity of emotional expression and reduced thought and speech productivity. More recently, a third category of symptom, disorganised, has been recognized. Disorganised symptoms include disorganised speech, disorganised behavior and poor attention. According to Diagnostic and Statistical Manual of Mental Disorder-IV (DSM-IV) (and the current DSM V), the essential features of schizophrenia consist of a e of characteristic signs and ms that have been present for a significant length of time during a 1-month period with some signs of the disorder persisting for at least 6 months. r no single symptom is teristic of the disease. Moreover, recognition of the heterogeneity of schizophrenia and psychosis has led to increasing dissatisfaction with tly used fication systems.

Current diagnostic ches are typically descriptive or rely predominantly on symptomatic es based on, for example, physical examination, gross medical evaluation, logical and/or psychiatric evaluation, anecdotal family history, and emotional history. There is a clear need for improved, objective, neuroscience-based methods for sing schizophrenia and psychosis. This would be greatly facilitated by the identification of markers schizophrenia and psychosis enabling the development of accurate, ive and easy to employ diagnostic tests.

Advances in tion have raised e expectations for phrenia, however a reduction in symptoms is far less-often accompanied by restoration of function and quality of life, despite the many psychosocial interventions ed. There are clear implications that other factors must contribute to this sustained reduction of functional ation. The novel mental illness model described herein identifies some of these unmet-need factors. It also provides a link between specifically problematic symptoms and behaviours of schizophrenia and their specific biological innings, so that management of difficult behaviour and distressing mental illness symptoms can be more clearly understood and more comprehensively managed.

Summary of the Invention According to a first aspect of the present invention there is provided a method for diagnosing phrenia, schizo-affective disorder and/or psychosis in an individual or predicting risk of the individual developing schizophrenia, schizo-affective disorder or psychosis, the method comprising (i) determining values for one or more markers in each of five domains: (a) a neurotransmitter domain (also referred to herein as the catecholamine domain) comprising dopamine, noradrenaline and adrenaline; (b) an oxidative stress domian comprising urinary hydroxyhemopyrrolineone (HPL) and urinary creatinine or other marker of oxidative stress; (c) a nutrition-biochemistry domain comprising free copper to zinc ratio, activated vitamin B6, red cell folate, serum vitamin B12, and vitamin D; (d) a visual processing domain comprising visual span, visual speed of processing discrepancy, visual speed of processing, and ce vision predominantly on the right; and (e) an auditory processing domain comprising e digit span, competing words pancy, auditory speed of processing discrepancy, and auditory speed of processing; (ii) comparing values for said one or more markers in each of said domains to control values of said markers in subjects not suffering from schizophrenia, schizo-affective disorder or psychosis, wherein the values of said markers indicative of schizophrenia or psychosis are, ve to said control : - in the neurotransmitter domain, high dopamine, high noradrenaline, and high adrenaline; - in the ive stress domain, high urinary hydroxyhemopyrrolineone divided by urinary creatinine; - in the nutrition-biochemistry domain, high free copper to zinc ratio (or low zinc to free copper ratio), low activated vitamin B6, low red cell folate, high serum vitamin B12, and low n D; - in the visual processing domain, low visual span, high visual speed of processing discrepancy (as percentage of age), low visual speed of processing (percentile), and poor distance vision, particularly on right; and - in the auditory processing domain, low reverse digit span, high competing words discrepancy (as tage of pass score), high auditory speed of processing discrepancy (as percentage of age), and low auditory speed of processing (percentile).

The psychosis may be schizophrenic psychosis or schizo-affective psychosis.

Typically the method comprises determining values for each of the markers in each of the domains as defined above.

Optionally, the method further comprises determining values for one or more markers in a middle ear domain comprising threshold ear canal volume, threshold peak middle ear pressure, threshold nt middle ear re, threshold stapes amplitude projected, threshold time to offset over baselength and threshold percentage ngth over duration, and ing values for said one or more markers to control values of said s in subjects not suffering from schizophrenia, schizo-affective disorder or psychosis, wherein the values of said markers indicative of schizophrenia, schizoaffective disorder or psychosis are, relative to said control values, high threshold ear canal volume, low threshold peak middle ear pressure, high threshold gradient middle ear pressure, high threshold stapes amplitude projected, low threshold time to offset over ngth and high threshold percentage baselength over duration.

In particular embodiments, said method comprises conducting statistical analysis of determined values of said markers in combination and diagnosing schizophrenia, schizoaffective er or psychosis in said individual on the basis of the combined analysis.

Typically said statistical analysis comprises receiver operating characteristic (ROC) analysis, and optionally odds-ratio calculation or regression analysis. Said ROC analysis may comprise ascertaining ROC ranges for individual ROC variables and summated sets of ROC variables and summated sets of ROC domain scores, based on ROC cut-off values, using an appropriate means to determine proxy standard deviation for ROC cutoff values adjusted for their position in the distribution of the variable. Odds ratio and regression analysis may be performed on summated ROC scores of multiple ROC domains to diagnose or determine risk prediction.

Biological samples obtained from the individual to determine marker levels for the ransmitter domain, the oxidative stress domain and the ion-biochemistry domainmay be derived from any suitable body fluid or tissue. For example the sample may se blood (such as erythrocytes, leukocytes, whole blood, blood plasma or blood serum), saliva, , urine, breath, condensed breath, ic fluid, cerebrospinal fluid or tissue (post-mortem or , fresh or frozen). In a particular embodiment the sample comprises whole blood, blood serum or urine.

The markers in the neurotransmitter domain and the nutrition-biochemistry domain are lly determined from blood or urine samples obtained from the individual, more typically from blood samples. The markers in the oxidative stress domain are typically determined from urine s obtained from the individual.

The method may further comprise the determination of levels of one or more additional markers in a sample d from said individual. By way of example only, additional markers measured may include abnormal old visual speed of processing performance (identified by increased interstimulus interval (ISI) required for correct visual order processing in msecs), al competing words (dichotic listening) performance (identified as low score on SCAN C competing words test or other dichotic listening test), abnormal threshold auditory speed of processing (identified by increased (ISI) required for t auditory order processing in , urinary hydroxyhemopyrrolineone (HPL) adjusted for urine nine or specific gravity of urine, methyl malonic acid, vitamin B2 (riboflavin), riboflavin cofactor 420, L- threonine, 5-methyltetrahydrofolate, osylmethionine (SAMe), S-adenosylhomocysteine (SAH), d glutathione and oxidised glutathione, wherein abnormal levels of methyl malonic acid, low vitamin B2, low 5-methyltetrahydrofolate, low or high SAMe, high SAH (and low or high SAMe:SAH ratio), low reduced glutathione and high oxidised glutathione in a sample obtained from the individual, compared to levels in subjects not suffering from schizophrenia, schizo-affective disorder or psychosis, are suggestive of schizophrenia, -affective disorder or psychosis.

Another aspect of the invention provides a method for evaluating the efficacy of a treatment regime in a subject suffering from schizophrenia, schizo-affective disorder and/or psychosis, the method comprising: (a) treating the subject with a treatment regime for a period sufficient to evaluate the efficacy of the ; (b) obtaining one or more biological samples from the subject; (c) determining the levels of a panel of markers in the (s) in accordance with the above-described first aspect; (d) repeating steps (b) and (c) at least once over a period of time; and (e) determining r the marker levels changes over the period of time.

Disease control in the subject may then be improved by adjusting the timing, frequency and/or intensity of marker testing and /or adjusting the identity, timing and/or intensity of a treatment regime to thereby normalise the levels of one or more of the markers.

Another aspect of the ion provides a method for designing a suitable treatment regime for a subject ing from schizophrenia, schizo-affective disorder and/or psychosis, the method comprising monitoring the levels of a panel of markers in the subject in accordance with the above described first , in the presence or absence of a treatment regime for treating the phrenia, schizo-affective disorder and/or psychosis and adjusting the identity, timing and/or intensity of the treatment regime so as to normalise the levels of one or more of the markers.

Also provided is a method for treating a subject suffering from schizophrenia, schizoaffective disorder and/or psychosis, comprising administering to the subject a treatment regime designed according to the above aspect.

Methods embodied by the above described aspects and embodiments of the ion are ularly suitable for sing and evaluating the status of phrenia, schizoaffective disorder and/or psychosis in human subjects. However, the invention is not limited thereto and extends to any mammal, for example mammals useful as a model for said disorders in . Typically the subject is a mammal, more typically a human.

The subject may be of any age, child, adolescent, adult or elderly.

Brief Description of the Drawings The invention will now be described by way of non-limiting example only, with reference to the accompanying drawings.

Figure 1. Percentage of symptomatic (case) and symptomatic (control) participants correctly identified by MIRAT Combined Model ed and non-imputed).

Detailed Description of the Invention The articles “a” and “an” are used herein to refer to one or to more than one (i.e. , to at least one) of the grammatical object of the article. By way of example, “an element” means one element or more than one element.

Throughout this specification and the claims which , unless the context requires otherwise, the word “comprise”, and variations such as “comprises” or “comprising”, will be understood to imply the inclusion of a stated element, integer or step, or group of elements, integers or steps, but not the exclusion of any other element, integer or step, or group of elements, integers or steps.

As used herein “MIRAT” refers to the Mental s Risk Assessment Test described and exemplified herein. MIRAT may also be referred to herein as the MIRAT multidomain model or the multi-domain model for schizophrenia and schizoaffective disorder.

The term "control" or "control sample" as used herein refers to one or more biological samples from individuals or groups of individuals classified as not having schizophrenia or psychosis and where the diagnosis for the "control" or ol sample" has been confirmed. A "control sample" may comprise the compilation of data from one or more individuals whose diagnosis as a "control" for the es of the t ion has been confirmed. That is, for the purposes of cing embodiments of the present invention samples to be used as controls need not be specifically or immediately obtained for the purpose of comparison with the sample(s) obtained from the subject under assessment.

The Mental Illness Risk Assessment Test is based upon a model of schizophrenia and schizo-affective disorder, composed of a number of combined biomarkers, d into a number of functional domains, designated herein as the “MIRAT Model”. This model outlines components that the inventor considers to be key ingredients of the phrenia, -affective er and psychosis (including schizophrenic and schizo-affective psychosis) conditions. The model consists of five main domains (referred to herein as the in model (5DM)) and one supplementary domain of bioneuro-sensory-cognitive markers (its ion giving the 6-domain model (6DM)). The first domain consists of measures of catecholamine neurotransmitter status (Neurotransmitter Domain), the second domain consists of a measure of oxidative stress (Oxidative Stress Domain), the third domain consists of measures of vitamin and mineral status (Nutrition-Biochemistry Domain), the fourth domain consists of measures of visual performance and sing (Visual Processing Domain), the fifth domain consists of measures of auditory performance and processing (Auditory Processing Domain), and the sixth and supplementary domain consists of measures of middle ear physiology and performance (Middle Ear Domain).

The Neurotransmitter Domain consists of three ponents these being Dopamine, Noradrenaline and Adrenaline.

The Oxidative Stress Domain consists of HPL/Creatinine and is interchangeably referred to herein as the HPL/Creatinine Domain.

The Nutrition-Biochemistry Domain consists of five subcomponents these being Serum B12, Red Cell Folate, Activated B6 oxal-5’-phosphate coenzyme form), the ratio of Free Copper to Red Cell Zinc, and Serum n D ( 25-OH).

The Visual Processing Domain consists of four subcomponents these being Visual (symbol) span, Threshold visual speed of processing performance as a percentage of age sses threshold visual order processing speed in terms of the visual processing ’s relative age), Visual speed of processing performance percentile, (expresses threshold visual order speed of processing performance as a percentile), and Distance vision predominantly on the right (binocular distance vision acuity).

The Auditory Processing Domain consists of four subcomponents these being Reverse digit span (measures auditory (verbal) working ), competing words performance for age as a percentage of age tic listening mance test, measures intracerebral processing of auditory information), threshold auditory speed of processing as a percentage of age (expresses threshold auditory order processing speed in terms of the auditory sing systems relative age), and auditory speed of processing performance percentile (which expresses threshold auditory order speed of processing performance as a percentile).

The Middle Ear Domain consists of six subcomponents these being Percentage length of the base of the stapes reflex divided by the total duration of the reflex (a measure of the strength of the stapes reflex during its maximal period of contraction), projected Stapes amplitude (alternative measure of stapes contraction strength), o-off-set of the stapes reflex contraction divided by the base length (gives a e of any acoustic reflex offset advance or delay), old ear canal , threshold peak middle ear pressure, and threshold gradient middle ear pressure.

Scaled median te deviation can be used to determine proxy standard ion for ROC cut-off values ed for their position in the distribution of the variable. Each subcomponent of the MIRAT Model is scored to a one or a zero using its unique cut-off value that was identified through ROC analysis. The subcomponent scores are tallied for the Domain and then the Domain is scored as a one or a zero based on its unique cut-off value that was identified through ROC analysis. Domains with missing subcomponent values but a sufficient subcomponent tally to code the Domain to one or zero are imputed. The scores for each Domain are combined (tallied) to provide a total score for the MIRAT multi-domain Model. The minimum score is zero and the maximum score is five. The combined MIRAT Model score is used to identify the risk of schizophrenia/psychosis being present and/or developing in the future. Non-parametric and gistic Regression models identify the risk of schizophrenia/psychosis based on a combined MIRAT Model score of 1 through to 5. A combined score of 3 or more abnormal Domains is indicative of a significant risk of diagnosis of schizophrenia/psychosis. The Middle Ear Domain is used in borderline cases to supplement the information provided by the main combined Five Domain Model.

As exemplified herein the inventor has d out a statistical analysis of biochemical markers, and cognitive and sensory processing measures in both the auditory and visual domains, from symptomatic schizophrenic participants and omatic participants.

Receiver operating characteristic (ROC) analysis identified a wide range of abnormal outcome measures across catecholamine, nutritional, auditory and visual processing and cognitive domains, confirming the heterogeneous nature of schizophrenic sis.

These markers were combined to form a combined model (MIRAT Model) of schizophrenia/schizo-affective disorder and psychosis, which demonstrated a sensitivity of 73-93% and a icity of 80-96% at the 95% level of significance. When odds-ratio analysis was performed (as described above), an abnormal score for three or more MIRAT model domains was ated with a diagnosis of schizophrenia, schizoaffective disorder or psychosis at 95% level of confidence and an abnormal score for four MIRAT model domains was highly associated with a diagnosis of schizophrenia or schizoaffective er at 95% level of ence. When regression-analysis was performed (as described above), a diagnosis of schizophrenia, schizoaffective disorder or psychosis was predicted at 95% level of confidence for three or more abnormal MIRAT model domains, with a score of four or five abnormal domains being highly predictive of a diagnosis of schizophrenia, affective disorder or psychosis, at a 95% level of ence.

Accordingly, the MIRAT model described herein provides a combination of biomarkers across multiple dimensions that possess diagnostic ing capacity for phrenia, schizo-affective disorder and psychosis, including schizophrenic and schizo-affective psychosis. A MIRAT assessment can be completed by a mental health professional, including general practitioners and nurse practitioners, within a half hour consultation time frame, in every day clinical settings with low t noise, using easily accessible, nsive ent and simple to apply methodology. The findings described herein and the employment of the MIRAT model has the potential to form the basis for a new paradigm and new psychiatric classification system for schizophrenia, schizo-affective disorder and psychosis.

In one aspect, the present invention provides a method for diagnosing phrenia, schizo-affective disorder and/or psychosis in an individual or predicting risk of the individual developing schizophrenia or psychosis, the method comprising (i) determining values for one or more markers in each of five domains: (a) a neurotransmitter domain comprising dopamine, noradrenaline and adrenaline; (b) an oxidative stress domain comprising urinary hydroxyhemopyrrolineone and urinary creatinine or other marker of oxidative stress; (c) a nutrition-biochemistry domain comprising free copper to zinc ratio, activated vitamin B6, red cell folate, serum vitamin B12, and vitamin D; (d) a visual processing domain comprising visual span, visual speed of processing discrepancy, visual speed of processing, and distance vision on right; and (e) an auditory processing domain comprising reverse digit span, ing words discrepancy, ry speed of sing discrepancy, and ry speed of processing; (ii) comparing values for said one or markers in each of said domains to control values of said s in subjects not suffering from schizophrenia, schizo-affective disorder or sis, n the values of said markers indicative of phrenia or psychosis are, relative to said l values: - in the neurotransmitter domain, high dopamine, high noradrenaline, and high adrenaline; - in the oxidative stress domain, high urinary hydroxyhemopyrrolineone divided by creatinine; - in the nutrition-biochemistry domain, high free copper to zinc ratio (or low zinc to free copper ratio), low activated n B6, low red cell folate, high serum vitamin B12, and low vitamin D; - in the visual processing domain, low visual span, high visual speed of processing discrepancy (percentage of age), low visual speed of processing (percentile), and poor distance vision on right; and - in the auditory processing domain, low reverse digit span, high ing words discrepancy (as percentage of pass score), high auditory speed of processing discrepancy (as percentage of age), and low auditory speed of processing (as tile).

Optionally, the method comprises determining values for one or more markers in a middle ear domain sing threshold ear canal volume, threshold peak middle ear pressure, threshold gradient middle ear pressure, threshold stapes amplitude projected, threshold time to offset over ngth and threshold percentage baselength over duration, and comparing values for said one or more markers to control values of said markers in subjects not suffering from schizophrenia, schizo-affective disorder or sis, wherein the values of said markers indicative of schizophrenia, schizoaffective disorder or psychosis are, relative to said control values, high threshold ear canal volume, low threshold peak middle ear re, high threshold gradient middle ear pressure, high threshold stapes amplitude projected, low threshold time to offset over baselength and high threshold tage baselength over duration.

Typically, the method comprises conducting statistical analysis of determined values of said markers in combination and diagnosing schizophrenia, schizo-affective disorder or psychosis is said individual on the basis of combined analysis. Typically said statistical analysis comprises receiver operating characteristic (ROC) analysis. In particular embodiments, said method comprises conducting tical analysis of determined values of said markers in combination and diagnosing schizophrenia, schizo-affective disorder or psychosis in said individual on the basis of the combined analysis. Said statistical is may comprise Receiver Operating Curve (ROC) ranges for individual ROC variables and ed sets of ROC variables, using an appropriate means to determine proxy standard deviation for ROC cut-off values ed for their on in the distribution of the variable. Statistical analysis may also comprise using ed sets of ROC domain scores, based on cut-off values, as described above and/or odds-ratio or regression analysis of the summated ROC scores of multiple ROC domains, for the purpose of association with sis or risk prediction. As exemplified herein, oddsratio analysis was performed to evaluate the association of the number of abnormal domains with a diagnosis of schizophrenia or schizoaffective disorder and regression analysis of summated ROC scores was performed to te the predictive capacity of the combined MIRAT ROC model (with imputed values). A tion correlation matrix comprised of Spearman correlation cients (rho), shows high level correlations with summated ROC model scores and sets of ROC variables for severity, disability and treatment resistance, demonstrated significance at the 95 per cent level of significance (see Examples).

In particular embodiments, individual components of the MIRAT multi-domain model are variables identified as significant on ROC analysis. These variables are gathered er into domains of interest, the ransmitter domain, the nutrition-biochemistry domain, the ive stress domain, the visual processing domain and the auditory processing domain in which, in particular embodiments, individual ROC component results are summated to form a model under the same name. When the five principal ROC models are in turn summated, they yield the combined ROC model (imputed), which is a biomarker model for schizophrenia, schizo-affective disorder and psychosis – also called “the MIRAT model”. When individual component variables within each domain are scored against their ROC cut-off point, they indicate whether or not a ROC domain itself is scored as abnormal. The score of number of abnormal ROC domain found, contributes to association with (odds-ratio) or risk of (regression-analysis), receiving a diagnosis of phrenia, as outlined in Tables 3 and 4 herein. The sixth domain (the middle ear domain) is an optional, supplementary domain, which can be used to increase risk prediction sensitivity in cases where prediction yields marginal or line results.

Typically an analysis in accordance with the present invention is carried out using each of the markers of the neurotransmitter domain, the oxidative stress domain, the nutritionbiochemistry domain, the visual domain and the auditory domain. A decision may be made by the assessing clinician as to whether or not to include the supplementary middle ear domain. For example, in cases where a diagnosis based on the neurotransmitter domain, the oxidative stress domain, the nutrition-biochemistry domain, the visual processing domain and the auditory processing domain may not be conclusive, it may be decided to proceed to middle ear testing and include the middle ear domain.

The multi-domain model (MIRAT) described herein is a novel approach collecting er biomarkers from five (and optionally six) different domains of ical, ensory and cognitive dysfunction. The domains of interest are represented by the neurotransmitter domain, the oxidative stress domain, the nutrition-biochemistry domain, the visual processing , the auditory processing domain, and optionally the middle ear domain. Within these domains are sub-components that are measures reaching ker status on ROC analysis and demonstrate an y to inform regarding the cumulative components of schizophrenia, schizo-affective disorder and psychosis, including schizophrenic and -affective psychosis, and also to both confirm association with and t risk of the diagnosis of schizophrenia, schizo-affective disorder and psychosis.

Biochemical tests used to ine biomarker levels in accordance with embodiments disclosed herein may be carried out utilising any means known in the art and the present invention is not limited by reference to the means by which the biomarker levels are determined. Determination of biomarker levels may comprise detection and/or quantitation and the methods and techniques available for such determination are well known to those skilled in the art. Suitable methods and techniques include, but are not limited to, the use of al analysis, column chromatography, gel electrophoresis, mass spectroscopy and identification of protein spots, enzyme-linked immunosorbent assay ), Western blot, photonic molecular sensing techniques, image acquisition and is (such as magnetic resonance imaging (MRI) spectroscopy and single photon on computed tomography (SPECT)) or other in-vivo imaging s.

Biochemical tests used to determine biomarker levels in accordance with embodiments disclosed herein may be employed in any suitable environment or setting, such as a hospital, clinic, surgical or medical practice, or ogy laboratory. Alternatively, or in addition, such biochemical tests may be orated into one or more devices capable of ing the desired biomarkers to thereby allow a degree, or complete, automation of the testing process. Suitable devices are typically capable of receiving a biological sample, analysing one or more biomarker levels in said sample and providing data on said biomarker level(s) in real time thus facilitating bench-to-bedside and point-of-care analysis, diagnosis, risk assessment and/or treatment. Suitable devices include, but are not limited to, the Cobas in vitro diagnostic systems (Roche Diagnostics). The device may be a handheld device or an assay device containing chip technology.

Similarly, measurements of sensory ters (including cognitive, visual, auditory and other ochemical markers) may be made using techniques and methodologies well known to those skilled in the art and the present invention is not limited by reference to the means by which such measurements are made.

Diagnoses and risk tions made in accordance with embodiments disclosed herein may be correlated with or determined in conjunction with tional ses, for example as generally exemplified by the International Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, (DSM IV or DSM IV-R) (the sure of which is incorporated herein by reference in its entirety) or DSM V or other international mental disease or symptom classification s known to those skilled in the art.

Accordingly, methods of the present invention may include assessment and/or monitoring in subjects of one or more symptoms associated with schizophrenia, schizoaffective er and/or psychosis. Without limiting the scope of the present disclosure, exemplary ms may include somatic concern, anxiety, depressed mood, suicidality, guilt, hostility, aggression, elated mood, grandiosity, pressure of speech, suspiciousness/persecution, auditory or visual hallucinations, ideas of reference or control, unusual or bizarre thought content, loose associations of thought, thought disorder, bizarre behaviour, self-neglect, arm, threats to others, disorientation, conceptual disorganisation, blunted or flat affect, emotional withdrawal, apathy, social withdrawal, social anxiety, motor retardation, tension, uncooperativeness, excitement, inattention, distractibility, motor hyperactivity, mannerisms or posturing, movement disorder, delusions, poor rapport, ity, poor ct thinking, d or absent theory of mind, reduced insight, reduced judgement, d short or long-term memory, anti-social traits, cies or acts, chronic regional pain or other unexplained chronic pain syndrome, offending behaviour of a forensic nature, disturbance of volition, poor impulse control, anger, delayed gratification difficulty, affective-lability, mood lability, mood swings, active social avoidance, preoccupation, obsessional preoccupation, ruminations, disturbance of spontaneity or flow of sation, poor self care, anxious worrying, tension, tonicity, grasp strength, rumination, fear, active/intentional and passive/unintentional avoidance, dissociation, stress, attenuated psychotic symptoms, overvalued on, brief intermittent tic symptoms, tive self-disturbance, re-experiencing phenomena, sense of presence, distancing, eality, disturbed stream of consciousness, self-other boundary disturbances, self-demarcation bances, bodyimage disturbances, anorexia, orientation and re-orientation disturbances, selfconsciousness , first rank ity ms, ideas of reference or control, loss of sense of self, thought insertion, thought broadcasting, thought blocking, thought replacement, abnormal perception, delusional attribution or interpretation, under-arousal, disinhibition, ivity, over-arousal, difficulty attending, reduced attention span, scattered attention, distressing recollections, emotional dysregulation, implausible belief, obsessional thought-preoccupation or thoughts, compensations, intrusive ry thoughts, euphoria, apathy, and irritability or poor impulse control.

In particular embodiments the symptom(s) assessed and/or monitored in subjects may e delusions, conceptual disorganisation, hallucinatory behaviour or hallucinations (visual, auditory or olfactory), excitement, agitation, tension, grandiosity, suspiciousness, persecutory thoughts, hostility, blunted affect, emotional withdrawal, poor rapport, passivity, apathy, social withdrawal, difficulty in abstract thinking, lack of spontaneity and flow of conversation, stereotyped thinking, c concerns, anxiety, fear, phobia, obsessional thoughts or behaviour, mannerisms and posturing, depressed mood, depression, motor retardation, catatonia, uncooperativeness, unusual thought content, disorientation, poor ion, poor memory, lack of ent and insight, disturbance of volition, poor impulse control, upation, active social avoidance, anger, difficulty in delaying gratification, ive (emotional) lability, suicidal thoughts, suicidal intent, suicide threat or completed suicide, self-harm thoughts, self-harm deeds, bizarre behaviour, elated mood, and guilt.

One advantage offered by the present invention is the ability to reveal to the clinician objective evidence of an individual’s areas of pathology and unmet needs in areas such as al neurotransmitters, vitamins and minerals (nutrition-biochemistry domain), visual and auditory processing, and middle ear performance. From this position, the clinician can initiate specifically targeted remedial interventions. For example, specific remediation of competing words (dichotic listening) deficit through dichotic training may be warranted, using for example the Digit Offset Therapy (DOT) approach. Specific remediation ques are ble for correction of each of the sub-component of the MIRAT model, and will be well known to those skilled in the art. Collaborative and simultaneous implementation of these remediation techniques may assist global correction of the schizophrenia/schizo-affective ion.

Accordingly, the present invention es methods for ining effective treatment regimes for sufferers of schizophrenia, schizo-affective disorder and/or psychosis, including schizophrenic and -affective psychosis, by carrying out diagnostic tests as described herein, optionally over time and determining if there is a change over time concomitant with, or resulting from, the employment of a specific treatment .

Also provided are methods for ring treatment s, including monitoring for treatment progress, preventing patient e or managing treatment resistance, by carrying out diagnostic tests as described herein over time and determining if there is a change over time itant with, or resulting from, the ment of a specific treatment regime. The above described methods optionally also se assessments and monitoring of one or more symptoms associated with schizophrenia, schizo-affective disorder and psychosis as described elsewhere herein. Thus, the present invention provides means of intervention in the treatment of a subject if necessary.

Accordingly, provided in an ary embodiment is a method for evaluating the efficacy of a treatment regime in a subject suffering from schizophrenia, schizo-affective disorder and/or psychosis, the method comprising: (a) treating the subject with a treatment regime for a period sufficient to evaluate the efficacy of the regime; (b) obtaining one or more biological samples from the subject; (c) determining the levels of a panel of markers in the sample(s) as disclosed herein; (d) repeating steps (b) and (c) at least once over a period of time; and (e) determining whether the marker levels changes over the period of time.

Disease control in the subject may then be improved by adjusting the timing, frequency and/or intensity of marker g and /or adjusting the identity, timing and/or intensity of a treatment regime to thereby normalise the levels of one or more of the s.

The term “disease control” as used herein means the status of the schizophrenia, schizoaffective er or psychosis, typically in light of ent or therapy intervention.

Thus “disease control” describes the range and severity of symptoms and conditions experienced and suffered by patients as a result of their schizophrenia, schizo-affective disorder or psychosis. Disease control effectively es a measure at a given point in time of the disease status of an individual, reflecting both current therapeutic treatment regimes used by the dual and the dual’s recent ences and psychological state.

Also provided in an exemplary embodiment is a method for designing a suitable treatment regime for a subject suffering from schizophrenia, schizo-affective disorder and/or psychosis, the method comprising monitoring the levels of a panel of markers in the subject as described herein, in the presence or absence of a treatment regime for treating the schizophrenia, -affective disorder or psychosis and adjusting the identity, timing and/or intensity of the treatment regime so as to normalise the levels of one or more of the markers.

The multi-domain model (MIRAT) and test as described herein enables a clinician to quantify and understand an individual’s areas of pathology and unmet needs in areas such as abnormal ransmitter levels, nutrition, visual and auditory sing, and middle ear mance. From this position, the clinician can become educated about the underpinnings of schizophrenia and/or schizoaffective disorder, and the underpinnings of their et symptoms and research evidence that already exists for specifically targeted remedial interventions in areas of unmet biological or neuro-sensory need.

The MIRAT multi-domain model has application for relapse-prevention, ng treatment-resistance and illness-prevention for schizophrenia and schizoaffective disorder. The multi-domain model and its MIRAT test may also be used to monitor al progress and determine treatment- response in the clinical setting. In the research setting it may be used to determine efficacy of new treatments for schizophrenia and/or schizoaffective disorder. The MIRAT multi-domain model also has application for neuro-cognitive-physiological and ical characterization of schizophrenia and schizoaffective disorder. Symptom profiles derived from kers within the MIRAT multi-domain model can assist the clinician to manage matic symptoms in a clinical setting where a MIRAT test is not available.

The following are provided, by way of example only, as means of employing the MIRAT model and its domains and their component ROC variables in relationship to key symptoms and behaviours associated with schizophrenia, schizo-affective disorder and psychosis: (1) There is a general need for knowledge about the underpinnings of classical psychiatric symptoms and behaviours and the MIRAT domainsmay serve as endophenotypes for schizophrenia. The MIRAT model itself has the potential to serve as a nidus or template for a new fication system for serious mental illness symptoms and behaviours. (2) It may also be that in some clinical settings such as rural and regional areas where full MIRAT model testing cannot be conducted, clinicians could still benefit from ch-based-evidence regarding specific substrates of a particular problematic behaviour and/or ms. Understanding these ours and/or symptoms in terms of their biological, nutritional and neurosensory/cognitive correlates, allows clinicians a broader range of responses in their ment of such conditions in the clinical setting. For instance, the knowledge that paranoid aggression and/or hostility correlates closely with certain nutritional and neuro-sensory and neurocognitive abnormalities, may assist to te urgent interventions that together with pharmacotherapy allows remediation of sion to a sub-threshold level, offsetting risks associated with management or containment. e.g. if it is known that an aggressive, hostile, paranoid patient is likely to have nutritional and auditory processing problems, nutritional replacement, ward milieu adjustment, ed staff communication style and in the longer-term ically targeted intervention, may assist to offset the severity of this behaviour. A further instance is the knowledge that suicidality, suicidal behaviour or intent may be associated with certain nutritional, neurotransmitter and neuro-sensory-cognitive abnormalities, may inform and assist prevention of suicide.

The present disclosure contemplates any suitable means of employing the MIRAT multidomain model g. For example, the model may be suitably employed via a computerised system, including an online, internet-based platform or via an app suitable for a er or personal electronic device such as a tablet, smartphone or other PDA or mobile device. Such an app may be developed for use on any operating system, including for example the Apple iOS and Android operating systems. ments sed herein also contemplate the use of one or more onal biomarkers to aid in diagnosis and risk tions. Such additional biomarkers may, for e, be used to validate or extend diagnoses made in accordance with the t sure. Such additional markers may be markers of, for example, inflammation, tissue damage, oxidative stress, urine excretion function and histamine metabolism.

Suitable 'validation' markers may include, for example, 1- methyl histamine, histamine, histidine, S-adenosyl-methionine (SAMe), S-adenosyl homocysteine (SAH), ratios between S-adenosyl-methionine and S-adenosyl homocysteine, serum/plasma adenosine, reduced and oxidised glutathione and ratios n reduced and oxidised glutathione, vitamin B2 (riboflavin) and associated molecules such as flavin adenine dinucleotide (FAD), flavin mononucleotide (FMN), F 450, L-threonine, quinone, semiquinone and flavin synthase, urine or plasma L biopterin, tetrahydro-L-Biopterin,(BH4) hydro- L-Biopterin (BH2) , BH4:BH2 ratio 5-hydroxy indole acetic acid, platelet monoamine oxidase, red cell yl transferase, catechol-O-methyltransferase polymorphisms, methyl tetrahydrofolate reductase polymorphisms (C667T and A1298C forms), thyroid stimulating hormone, serine, glycine, thromboxane, urine llinate, vanilmandelic acid, serum creatinine, immunoglobulins A, E, G, & I., IgG and IgE food allergy screens, IGE allergy correlates, all inflammatory cytokine levels, TNF alpha and interferon kappa B, C reactive protein, serum iron (ferritin, transferrin, transferrin saturation), serum, plasma or y lead, iadin antibodies, red cell/serum magnesium, serum calcium, free m concentration, blood sugar and plasma insulin, N-acetylaspartate, D glucaric acid, phosphocreatinine, glutamate dehydrogenase, N methionine adenosyl erase, plasma l, B-retinylacetate, B-retinoic acid, tyrosine hydroxylase, thyroxine T3, T4 and reverse T3 components, serum creatinine, prostoglandin E1, catalase (CAT), reduced glutathione (GSH), oxidised glutathione (GSSG), antioxidant ratio (GSH/GSSG), vitamin C, albumin, nicatimamide adenine dinucleotide (NADPH oxidase) deficit, glutamate-cysteine ligase (GCL and GCLC), ol phosphate (GAPDH), haeme oxygenase (HO-1), otyrosine (3NT), 8 oxo-deoxyguanosine (8-oxo-dG), 3 chlorotyrosine (3-CT), aconitase activity, H2DCFDA (DCF), advanced glycation end t (CML) or lipid peroxidase marker (HNE).

Further additional markers that may be ed or assessed in conjunction with the markers hereinbefore disclosed and in accordance with embodiments disclosed herein include, but are not limited to: urinary porphyrins including total urinary haeme, y precoproporphyrin (COPRO), keto-isococoporphyrin, urinary uroporphyrin (URO), urinary roporphyrin (PRECOPRO), PRECOPRO:URO ratio, uroporphyrin decarboxylase (UROD), cocoporphyrinogen oxidase (CPOX), hepta and rboxyporphyrins, 5-aminolevulinic acid (gamma ALA), urinary orphyrinogen and faecal isococproporphyrin); serum/plasma 1 methyl histamine; tGSH:GSSG ratio; glutathione peroxidase; superoxide dismutase; glutathione S transferase P1 (GST P1); glutathion-S-transferase M1 (GST M1); urinary alphahydroxybutyrate; urinary DHPG : MHPG ratio; ur inary pyroglutamate; urinary sulphate; urinary 8-hydroxydeoxyguanosine; red cell folic acid; red cell methyl malonic acid; urinary forminoglutamate; serum/plasma adenosine; red cell pyridoxine activation test; red cell transketolase; red cell pyridoxal phosphate activation test; plasma cysteine; total glutathione (reduced) glutathione (GSSG); urinary or plasma tetrahydrobiopterin BH4; red cell pyridoxine activation test; red cell transketolase; urinary xanthurenate; urinary kynurenate; 25 y cholecalciferol; vitamin D receptor polymorphisms; urinary DOPAC: HVA ratio; vitamins CoQ10, E, A, or D; y adipate; urinary suberate; urinary ethylmalonate; APOE polymorphisms; urinary methylmalonate; serum/plasma methionine; serum/plasma S adenosyl methionine; red cell magnesium; serum magnesium; serum Fe 10; ferritin; errin; serum cortisol; DHEAS; urine ole acetic acid, whole blood histamine, substance P; urinary etoisovalerate ; y alpha-ketoisocaproate; urinary alpha-keto-b-methylvalerate; urinary ydroxyisovalerate; urinary HIAA (5-hydroxyindoleacetic acid); urinary DOPAC (3 -methoxytyramine); ine methyl transferase, urinary HVA (homovallinate); urinary DHPG (dihydroxyphenylglycol); urinary MHPG (urinary 3- methoxyhydroxyphenylglycol); urinary DOMA:VMA; red cell catechol-o-methyl transferase (COMT) including polymorphisms; MRNA for 7 nic acetylcholine receptor, choline creatinine ratio, phosphocreatinine, alpha C-methyl-L-tryptophan trapping, N acetyl aspartate, eosinophil protein X and eosinophil calprolectin, plasma S adenosyl homocysteine; S adenosyl homocysteine hydrolase; platelet catecholamines; urinary hydroxymethylglutarate; blood lymphocyte 7 nicotinic acetylcholine receptor, IGG food allergy screen; imidazole N-methyl transferase., B2 microglobulin; antigliaden autoantibodies (such as tissue transglutamase IGG, tissue transglutaminase IGA, Methionine adenyl transferase, endomysial antibody); urinary oxyphenylacetate; CD8 and SD4 T cell levels; inflammatory cytokine levels; urine methyl histamine, urine histamine, C reactive protein; erythrocyte or serum N methyl transferase, nerve growth ; arginine N methyltransferase; urinary VMA (vanilmandelic acid); vesicular monoamine trasnporter ); neuronal nitric oxide synthetase; alpha-C methyl-L- tryptophan; acetyl cholinesterase, choline acetyltransferase; vesicular acetylcholine transporter; and tyrosine hydroxylase; red blood cell choline, alpha 7Acetylcholine receptor activity, alpha 4 acetylcholine receptor activity, choline esterase, ic acid decarboxylase, taurine, ine, kainate, glycine, spermine, spermidine, glutamate, substance P, aspartate, biotin,, quinolones, quinolinate, inic acid, picolinate, kynurenic acid, free androgen index, urinary phydroxyphenylacetate, serum ine, urinary DOMA (3,4-dihydroxymandelic acid); plasma nitrous oxide; Cu:Zn ratio (N 0.8-1.2); free copper (Cu); urine histamine; plasma chromium; whole blood serum and urine lead (Pb), mercury (Hg) and cadmium (Cd); hair mineral analysis for cadmium, mercury, arsenic, lead, copper, chromium, lithium, sodium, potassium, bismuth and de; urine whole blood, red cell and/or serum assays of vitamin A, plasma -malonic acid; plasma, blood and/or urine assay of pyridoxinephosphate (P5P), pyridoxil kinase, niacin, niacinamide, red cell transketolase; thyroid stimulating hormone; thyroid peroxidase antibodies; free T3 and T4; reverse T3; serum cortisol; urinary iodine, urinary folate as urinary fromino-glutamic acid (FIGLU); urinary N- methyl- Nicotinamide.methylmalonic acid; erythrocyte glutamic-pyruvic transaminase (EPGPT); ic-oxaloacetic transaminase (EGOT); serum levels of electrolytes, Ca++ , Mg ++ and BSL; ferritin; biopterin; C- reactive protein (CRP); serum and/or red blood cell assay of manganese; secretory IGA; serum IGA, IGG, IGM and IGE; IGG and IGE for gluten and casein ivity; red cell fatty acids; arachadonic acid (AA):EPA ratio; lipid peroxidises; H2O2; t-butylhydroperoxide; cumene hydroperoxide; 2-thiobarbituric acid reactive substances (TBARS); apometallathionein; glutamic decarboxylase; ive stress biomarkers including 8 hydroxydeoxyguanosine (8-OhdG), malondialdehyde (MDA) and isoprostane; glutathuione peroxidase x); superoxide dismutase (SOD); urine lipid des; hydroxy catechol markers; glutathione transferase; S adenosylhomocysteine hydrolase; spinal motor neuron survival gene (SMN); red cell and/or serum methionine adenosyltransferase; S-adenosyl-L-methionine synthetase; nine breath test; adenosine deaminase; urinary indicans; valerate isobutyrate; urine analysis of ose, mannitol and lactulose:manitol ratio after lactulose mannitol challenge; serum cholesterol; triglycerides; uric acid; serum iron; ferritin, transferrin and transferrin saturation; aspartate amino erase (ALT), alanine amino transferase (AST); lactic dehydrogenase (LDH); low density lipoprotein (LDL); tissue transglutaminase IgG; tissue transaminase IgA; endomysial antibody; calprotectin and eosinophil protein X; interleukin IB; serum testosterone; free androgen index; DHEAS roepiandosterone); antigliadin IgA; serum lutaminase IgA antibody; gliadin IgG antibody; full blood count; haemoglobin; faecal PH; cholesterol; pancreatic se; n butyrate; e; propionate; faecal total short chain fatty acids; total long chain fatty acids; faecal microbiology, mycology and tology; glycine:glucuronide ratio; sulphate:glucuronide ratio; D glucaric acid; glutamate dehydrogenase; urinary amino acids such as histidine, isoleucine, leucine, lysine, methionine, phenylalanine, threonine, tryptophan, valine, cysteine, glutamine, taurine, tyrosine, alanine, arginine, aspartic acid, glutamic acid, glycine, proline, serine, aspartate, asparagine, tyrosine, glutamine and glutamate; copper/zinc superdioxide and catalase activity; ESR; IL-1B (interleukin 1B); tumour necrosis factor alpha pha) and serum alpha1, alpha2 and gamma fractions; platelet glutamate levels; serum holotranscobalamin; adenosylcobalamin, NMDA receptor NR2B subunits and other sub unit or activity; blood trype; prostoglandin E1; brain derived neurotrophic factor Val/Met polymorphisms; 5HTT-LPR polymorphisms; thiamine; omega 3; omega 6; retinoic acid; tene; UA B30; blood diamine oxidase activity; blood or urine urea; blood or serum thyroxine transthyretin, thromboxane, blood or urine ammonia concentration; urinary amino-n-butyric acid; foramino glutamic acid; urine anserine; urine sarcosine; alpha-ketocaproic acid; beta aminoisobutyric acid.urine ic acid; glutaric acid; and glutamine/glutamate ratio; pyroglutamic acid; 3 –hydroxypropionic acid. dihidroxyphenylpropionic acid; urine arginine/ornithine ratio; citruline; kynurenic acid; serine; tyrosine; 3 methoxyohphenylglycol ; taurine; 4-hydroxyphenylpyruvic acid; suberic acid; pyruvic acid; 5 hydroxyphenylpyruvic acid; citric acid; cisaconitic acid; citric acid; aspartic acid; lactic acid; adipic acid; phenyl acetic acid; oxy indolacetic acid; dihydroxyphenylpropionic acid; 2–hydroxyphenylacetic acid; ne homogentisic acid; benzoic/hippuric acid ratio; lipid peroxidases; carnosine; alpha- amino-n- butyric acid; alpha ketovaleric acid; alphaketomethylvaleric acid; alpha ketovaleric acid.; succinic acid; urine beta aminoisobutyric acid; aminoisobutyric acid; indoleacetic acid; acetic acid; arabinose; malic acid; homogentistic acid; urine methylmalonic acid; urine homocysteine; urine 1-methyl histidine; 3-methyl histidine. urine succinyl purine; inosine; adenosylcobalamine coenzyme; proline; phosphoserine; ethanolamine; urine phosphoserine; urine hione; ine decarboxylase (HDC), histamine-N-Methyl transferase (HNMT), monoamine oxidase A, phosphoethanolamine; orotic acid; urine n methylglycine; urine opiate peptides; IgG and IgE anti casein and gluten antibodies; plasma ; plasma e; serine hydroxymethyltransferase; C14 or C11 labelled CO2 following C14 - or C11 -methionine administration; histamine N methyl transferase (HMT); plasma glycine; methylcytosine binding protein (MeCP2); histone(H4) deacetylase; acetylated histone(H4); plasma pyridoxyl phosphate; glutathione-S-transferase; cystathione beta synthetase (CBS, CbetaS); cysteine beta tase (CBS), S adenosyl homocysteine hydrolase (SAHH), serine hydroxymethytransferase (SHMT), te oxidase, plasma alkalinepyridoxine phosphate phosphatise; mitogen phytohemagglutin (PHA); serum histamine(2-(4 – Imidazolyl)-ethylamine); red blood cell histamine; erythrocyte histamine-N- methyltransferase; glycine-N-methyltransferase; retinol binding globulin; glutathione- S- transferase; e acetyl transferase: to acetylcholine esterase ratio, betaine homocysteine methyl transferase (BHMT), 5 methylhydrpofolate-homocysteine S methyltransferase, methionine synthetase (MS), methionine synthetase ase, tryptophan hydroxylase, tyrosine hydroxylase, urine yltryptamine (DMT); fasting blood alanine; blood lactate:pyruvate ratio; blood acetyl-carnitine: free carnitine ratio; beta casomorphin-7; casomorphin; influenza titre; glutamic acid decarboxylase 65 & 67 KDA; indoleamine 2,3,-dioxygenase (IDO), tryptophan 2,3-dioxygenase (TDO), reelin proteins; plasma rennin; serine hydroxymethyltransferase; hione synthetase; heart rate; blood pressure; continuous task performance; saliva cortisol; catecholamines (noradrenalin and adrenalin and metabolites); corticotrophin releasing factor; c screen, urine nate, acetate, faecal PH; terol; pancreatic elastase; n-butyrate; acetate; propionate; faecal total short chain fatty acids; total long chain fatty acids; faecal microbiology, mycology and parasitology, hippurate. benzoate, faecal micro-organsim aerobe and anaerobe DNA and mRNA analysis, Glutathione synthetase, glutathione peroxidase, superoxide ase (SOD), glutathione-S-transferase P1, glutathione-S- tranferase M1, thiobarbituric reactive nces (TBARS), nitric oxide, glutathione peroxidise (GP), copper/zinc superoxide dismutase (SOD), copper/zinc superoxide ase, sulphate to sulphide ratio, lipid peroxidases, urine or other bodily fluid a level/concentration, blood ammonia and expired or other ammonia levels , sulphite oxidase, lymphocyte DNA methylation, 8 hydroxy-deguanosine, hydroxyl dehydroxyguanosine, C ve protein, orotate, tricarb valerate, Kynurenate: quinolinate ratio, glutamate:semiquinolone ratio, dimethyltryptamine L phan, glutamate/dopamine ratio, noradrenaline:substance P ratio, plasma or urinary formate or formic acid, kynurenate/kynurenic acid ratio, lactoferrin,, urinary alphahydroxybutyrate, urinary sulphite to sulphate ratio, red blood cell Catechol-o-methyltransferase activity, histamine-n-methyltransferase activity. 3 y kynurenine, xanthurenic acid, cystathione, neopterin, arginine:citrulline ratio, plasma oxytocin, thioredoxin (TRX), alanine amino transferase (ALT), gamma-aminobutyric acid (GABA), parvalbumin immunoreactivity .

For markers listed above, measurements may be made of levels, ratios and/or activities, affinity, radioligand binding levels, or other means of biomarker or receptor activation assessment, subunit messenger RNA expression and levels as appropriate. For s, measurements may be of levels, activity, V max and/or Km, kcat, m. For genes listed, measurement may be of single tide polymorphisms and isomers, sequence deletions, inclusions, repetitions, isomers, missense mutations, micro DNA or abnormalities of specific interest.

Biological s used to determine levels of any biochemical markers contemplated herein may be derived from any suitable body fluid or tissue. For example the sample may comprise blood (such as erythrocytes, leukocytes, whole blood, blood plasma or blood serum), saliva, sputum, urine, breath, condensed breath, amniotic fluid, cerebrospinal fluid or tissue (post-mortem or , fresh or frozen). In a particular embodiment the sample comprises whole blood, blood serum or urine. In specific embodiments of the present invention the markers in the neurotransmitter domain and the nutrition-biochemistry domain are typically determined from blood or urine samples obtained from an individual to be assessed, more typically from blood samples. The markers in the oxidative stress domain are typically determined from urine samples obtained from an individual to be ed.

In diagnosing schizophrenia, schizo-affective disorder and psychosis, including schizophrenic and schizo-affective psychosis, and predicting association with schizophrenia or risk of an individual developing schizophrenia, schizo-affective disorder or psychosis, including schizophrenic and schizo-affective sis, in accordance with embodiments disclosed herein, determination of markers as disclosed herein may be used in conjunction with a range of other sensory-based, cognitive and behavioural tests known and available to those skilled in the art including, for example, Go-NO-GO test, digit-symbol processing speed and accuracy test, an acoustic reflex and reflex decay test; anxiety potentiated startle reflex; startle reaction time; acoustic startle (threshold, inhibition and affective inhibition); auditory brain stem responses (ABR) such as stimulus old, rm morphologies, absolute and relative amplitudes, latencies, middle latency response (MLR) and relative interpeak latencies for ABR waves N1, Na, Pa, Pb and late latency response (LLR), N1, P2 and P3 (P300) components, auditory tone (pitch) discrimination test, division of auditory attention test, filtered word test, auditory figure ground test, visual field evoked response test, prepulse inhibition test, quantitative EEG and topographic mapping of alpha, beta, theta and delta waves and all possible power ratios between these waves, including absolute power, relative power and power ve to normal data base, al analysis, independent component analysis, Z score analysis and signal source analysis; visual response search score; eye blink rate; mismatch negativity; auditory (and visual) evoked response potentials and the P 50, N1, P1, N2, P200, P250 and P300 components of the evoked response and their amplitude laterality discrepancies and eak latencies, rade ; immediate memory; memory selection; ive function; N-back test; se speed; directed ng task; go/no go response tion; internal/external locus of l; strength of memory score; memory tests (e.g. Ray copy/recall, RAVLT and RAVLT errors., SILS, quick T, IT); saccadic eye movements; antisaccade task; EEG gamma band synchrony; and auditory (and visual) evoked response tests, components ing mismatch negativity component (MMN), N1, P50, P400, P3a and P3b components during a ive task, contingent negative variation component (CNV) and post-imperative negative variation (PINV) component Auditory Brain stem Response (ABR) stimulus threshold, waveform morphologies, absolute and relative amplitudes, ies, middle latency se (MLR) and ve interpeak latencies for ABR waves N1, Na, Pa, Pb and late latency response (LLR), N1, P2 and P3 (P300) components, ABR frequency and amplitude laterality differences, ABR interpeak latencies, frequency and power analysis of BOLD fMRI signal for sensory, motor, cognitive or integrated tasks and/or brain networks.

All publications mentioned in this specification are herein incorporated by reference.

The reference in this specification to any prior publication (or information d from it), or to any matter which is known, is not, and should not be taken as an acknowledgment or admission or any form of suggestion that that prior publication (or information derived from it) or known matter forms part of the common general knowledge in the field of endeavour to which this specification relates.

It will be appreciated by persons skilled in the art that numerous variations and/or modifications may be made to the invention without departing from the spirit or scope of the invention as broadly described. The present embodiments are, therefore, to be considered in all respects as illustrative and not restrictive.

The present invention will now be bed with reference to the following ic examples, which should not be ued as in any way limiting the scope of the invention .

Examples Example 1 – Assessment methodology Subject recruitment Ethics permission for the study was obtained from the Queen Elizabeth Hospital Ethics Committee. Data from an earlier pilot study indicated that a m of 60 cases was needed to ensure a minimum level of significance of 90 per cent. Symptomatic participants (67 cases) were recruited from ward and community settings. Diagnoses were made by DSM IV-R criteria and were verified by the R symptomchecklist.

Pharmacotherapy of symptomatic participants remained stable during the assessment period. Persons medicated with Clozapine, Olanzapine, or istamines or vitamins were excluded. Persons with substance abuse, upper respiratory tract infections, intellectual, visual or auditory disability or documented history of head injury or extrapyramidal or motor abnormality of ocular, forearm or hand muscle movements were also excluded.

Asymptomatic mentally healthy control participants (67) were collaterally randomly selected and recruited with the ance of the Population Research and Outcomes Studies (PROS) Unit of the University of Adelaide, via the Queen Elizabeth Hospital North West Adelaide Cohort (Health Study). In order to obtain younger controls for age and sex matching, a small number of volunteers were recruited from local surf life-saving clubs. Volunteer persons with a history of mental illness, substance abuse, or visual or hearing disability, learning disability, or taking anti-histamine medication or vitamin supplementation were ed from selection.

Specimen collection and biochemical assays Neurotransmitters Compromised cooperation in psychotic participants precluded collection of 24 hour specimens, therefore ght-rested and fasted participants self-collected 50 millilitres of urine um of 2 hours separation from blood tion) for biogenic-amine analysis of dopamine, enaline, and adrenaline. Dopamine, noradrenaline and adrenaline were measured by SA Pathology using known, e methods. Pathology using a fasting and predominantly second void morning spot urine sample. Urine was snap-frozen to minus 30 degrees and batch transported weekly to the laboratory.

Biogenic amines were analysed by mass spectrometry, using urinary creatinine as a standard, with s presented as nmol/mmol of creatinine.

Creatinine Creatinine in mmol/L was measured by SA Pathology using a spot urine specimen from the same void as the sample provided for HPL and urinary catecholamine assay.

Urinary hydroxyhemopyrrolineone (HPL) Urinary hydroxyhemopyrrolineone (HPL) analysis was conducted by Applied Analytical Laboratories. Predominantly second void specimens were collected into vials containing ascorbic acid as a preservative. These were snap frozen (-30oC) and protected from direct light until quantitative analysis was undertaken by colorimetric method at 540nm, following solvent extraction and reaction with Erich’s reagent.

Vitamins and minerals All n and mineral blood samples were fasting g blood taken at a period separated from urine collection by at least one hour. Vitamin D (25 OH form) was measured by th laboratories using the in Liason assay method. Serum B12 was ed by Clinpath laboratories using the Roche Modular Immunoassay and reported as pmol/L. Red Cell Folate was measured by Clinpath laboratories using the Roche Modular Immunoassay and reported as nmol/L. Pyridoxal-5’-phosphate (vitamin B6 coenzyme form) was measured and ed in whole blood using High Pressure Liquid Chromatography by Sullivan Nicolaides Pathology on behalf of Clinpath laboratories, and reported in nmol/L. Serum Copper was measured by Douglass Hanly Moir Pathology on behalf of Clinpath laboratories using atomic absorption method and reported in umol/L. Red Cell Zinc was measured by Sullivan ides Pathology on behalf of Clinpath tories by fluorometric method on a Helena Lab instrument, and reported in umol/L. Ceruplasmin was measured by Douglass Hanly Moir Pathology on behalf of th laboratories using the Siemens IMMULITE® 2000 immunoassay system, and reported in g/L. The percentage of free copper in the serum was calculated by an on based on the molecular and atomic weights of ceruloplasmin and copper (one ceruloplasmin molecule binds to six copper atoms). The ratio of the percentage free copper to red cell zinc was calculated as “Percentage free copper” / “Red cell zinc umol/L”.

Sensory processing assessment Sensory processing assessors were blind to laboratory results but unavoidably aware of residual symptoms of psychosis displayed by some patients during test-procedures.

Visual assessment Visual outcome measures were obtained for visual acuity, attention span, speed and accuracy of visual sing. Visual assessment was conducted using the participant’s usual s (when applicable). Alternate-cover-test was ted to exclude visual fixation disparity (phoria).

Visual span Visual-spatial attention was assessed using The Visual Symbol Test, a subset test of WMS-IV (Weschler Memory Scale) reported as the absolute number of visual symbols directly replicated in the t order.

Distance vision The Snellen-Chart was used to assess distance vision on the left and the right of test subjects. Only distance vision on the right yielded a statistically significant .

Visual speed of processing performance as a percentage of age and Visual speed of processing performance percentile Visual speed of processing was assessed using the Brain Boy Universal Professional instrument (MediTECH Electronic GmbH). The Brain Boy Universal Professional BrainB-v (Order-v) test measures visual speed-of-response for correctly identifying the first ance of two visual stimuli es) that are randomly presented from left-toright or right-to-left on le occasions, until a threshold response speed is determined, expressed as the inter-stimulus interval (ISI) in msecs. The term hold” used herein refers to the lowest ISI level at which correct visual order processing (best performance) can be obtained. A read out of the threshold speed of visual ) processing is then provided, as is a performance-age rating, which has been configured against norms-for-age in the stored data-base. For adults between the range of 18 and 60 years, the normal range for visual speed of (order) processing is 24 to 72 milliseconds.

The MIRAT multi-domain model variable, termed the Visual speed of processing performance as a percentage of age was calculated by cting the norm-for-age from the performance-age provided, which was then divided by the age of the test subject, and then multiplied by one hundred. ry processing assessment ry outcome measures were of conduction, acuity, attention, threshold speed & accuracy of auditory processing. Assessments were conducted in a quiet room.

Preliminary examination of the external-auditory-meatus, excluded obvious tympanicpathology and sebum-obstruction. etry examination identified undetected earlydeficits in auditory-processing, as determined by ing air-bone conduction-gap at threshold or neurosensory-deficits in the speech and language range (1000 to 4000Hz) on the MAICO ram MA 40 (MAICO Diagnostic GmbH).

Reverse digit span Reverse digit span is a subset of the Wechsler Adult igence Scale-III (WAIS-III), 1997 that is delivered verbally and measures auditory (verbal) g memory. The MIRAT variable Reverse digit span was reported as the absolute number of digits correctly recalled in reverse order.

Competing words (performance for age as a percentage of age) The SCAN-3 auditory ing test for adults was used to assess intra-cerebral processing of auditory information. The SCAN-3 is a validated, standardised, screening test using a voice-over CD and nes to present the brain with several types of auditory challenge. One challenge comprises a dichotic-listening test that assesses ability to tly identify both of two competing-words (CW), delivered separately to the right and left ears. Using this test’s normative-for-age database, the difference between each test subject’s expected and actual performance-for-age was calculated, and this was then divided by the age of the test subject, and then multiplied by one hundred, to create the MIRAT variable Competing words (performance for age as a percentage of age).

Auditory speed of processing performance as a percentage of age and Auditory speed of processing performance percentile The Brain Boy sal Professional BrainB-a (Order-a) test measures auditory speedof-response for correctly identifying the first side of hearing two auditory stimuli (clicks) that are randomly ted from left-to-right or right-to-left on multiple occasions through headphones, until a threshold response speed is determined, expressed as the inter-stimulus interval (ISI) in msecs. The term hold” used herein refers to the lowest ISI level at which t auditory order processing (best performance) can be obtained.

A read out of the threshold speed of auditory (order) processing is then provided, as is a performance-age rating, which has been configured against norms-for-age in the stored database. For adults between the range of 18 and 60 years, the normal range for auditory (order) speed of processing is 46 to 72 milliseconds.

The MIRAT multi-domain model variable, termed Auditory speed of processing performance as a percentage of age was calculated by subtracting the norm-for-age from the performance-age provided, which was then divided by the age of the test subject, and then lied by one hundred. The MIRAT variable termed the ry speed of processing performance percentile was calculated from the norm age reference/performance ranges for the Brain Boy Universal Professional.

Measures of middle ear compliance and conductance involving tympanic and stapes muscle-contraction Ear canal volume at threshold auditory response, peak middle ear pressure at threshold ry response, and the gradient of the middle ear pressure was measured with the Auto Tymp GSI 38 by VIASYS Healthcare. This instrument es the ters of the acoustic reflexes, consisting of the tympanic muscle reflex response to sound entering the ear, along with the strength and duration of stapes muscle reflex which dampens the middle-ear-conducted auditory signal entering the cochlear. In relationship to these middle ear ic reflexes, the term hold” refers to the first reflex se which typically occurs at a frequency of 500Hz in a decibel range of 90 to 110. (There was no significant differences in decibel or Hz threshold response ranges between cases and controls).

Percentage length of the base of the stapes reflex divided by the total duration of the reflex The GSI 38 traces the stapes reflex contraction to maximum ude of 8 millimetres, after which it traces a basal threshold formed for the maximum portion of the reflex. The length of this basal portion divided by the total duration of the reflex contraction, expressed as a percentage, was a measure of the strength of the stapes reflex during its maximal period of contraction.

Stapes amplitude (projected) Stapes ude projected is an alternative measure of stapes contraction strength obtained by ing stapes amplitude at the intersection of projected onset and offset contraction gradients.

Time-to-off-set of the stapes reflex contraction divided by the base length The base length as described above was compared with the total duration of the stapes reflex, from its initiation to its time of offset. This gave a measure of any stapes acoustic reflex offset advance or delay in applying the handle of the stapes to the window of the cochlea. ty and disability outcome measures Participants were rated on the Clinical Global sion of Severity (CGI), Global assessment of Function (GAF), and Social and Occupational Functioning Assessment Scale (SOFAS). Number of readmissions of each patient was taken as a measure of treatment resistance. The Brief Psychiatric Symptom Scale (BPRS), has many symptomoverlaps with those of the Positive and Negative Symptom Scale for schizophrenia (PANSS), and these two scores were amalgamated in the interest of reducing participant ment time. The BPRS es ity sub-scores (1-7) for rating each symptom.

The rating level for each symptom was summated to give a symptom-intensity-rating (SIR) index for each ipant. Symptomatic patient-participants and asymptomatic control-participants were rated for symptoms using these measures. Ratings were collected by a single researcher, who was blind to laboratory results at the time of testing.

Statistical analysis Statistical analysis was complicated by the lack of normal distribution in the variables that itated the use of non-parametric methods of analysis and data modelling.

Scaled median te deviation (sMAD) was used to determine proxy standard deviation for ROC cut-off .

Table 1 summarises the principle characteristics of the variables composing the MIRAT model.

Table 1. Distribution summary for variables in the MIRAT multi-domain Model sMAD = Scaled median absolute ion Scaled Obs. Median Fitted without Min- Max- Med- Absolute distrib- No missing ion ROC Variable Obs data imum imum Mean SD ian sMAD ution Visual Domain Visual span 134 126 0.00 8.00 5.476 1.35 6.00 1.00 Pert Visual speed of processing discrepancy (% Log of age) 134 122 -90.00 207.69 6.01 54.44 -5.55 30.24 Normal Distance vision Chion right 134 128 0.00 36.00 7.98 6.03 6.00 1.50 square Auditory Domain Reverse digit Gamma span 134 127 2.00 8.00 4.22 1.33 4.00 1.00 (3P) Competing words discrepancy (% Johnson of pass score) 134 124 -69.23 50.00 0.55 22.61 3.84 15.38 SB Auditory speed of processing Gen. discrepancy (% - Extreme of age) 134 121 -100.00 220.00 -3.83 56.68 18.00 31.12 Value Catecholamine Domain Dopamine 134 133 45.00 358.00 142.47 53.64 129.0 32.00 Logistic Johnson enaline 134 133 3.00 106.00 25.278 18.53 19.00 9.00 SB Adrenaline 134 133 0.00 27.00 4.413 5.10 2.00 1.00 Logistic HPL/Creatinin e Model 134 133 0.35 40.04 4.586 5.94 2.47 1.18 Burr Nutrition- Biochemistry Domain Free copper to Log- Zinc ratio 134 133 -1.85 1.60 0.267 0.52 0.31 0.31 Logistic Extreme B6 activation 134 129 12.80 1570.0 140.44 164.6 90.00 25.00 Value Red cell folate 134 133 506.00 3291.0 1788.9 448.7 1733. 236.00 Logistic Extreme Serum B12 134 134 42.00 1388.0 406.15 178.5 367.0 104.00 Value Vitamin D 134 132 13.00 149.00 52.462 22.15 52.00 14.00 Dagum Middle Ear Domain Threshold ear 1,100 e canal volume 134 123 0.000 8000 1.2130 0.722 0 0.3000 Value Threshold peak middle ear minus minus minus pressure 134 124 275000 20,000 29.072 44.48 15.00 10.0000 Cauchy Threshold gradient middle ear re (90 Logpercent ) 134 124 0.000 165,00 60.797 31.37 55.00 20.0000 Logistic Threshold stapes amplitude Gumbel projected 134 123 0.000 30.000 11.813 6.662 1.000 4.000 Max Threshold time to offset over base length 134 122 0.000 80.000 13.038 22.04 1.760 0.6300 Burr Threshold percentage base length over Gen duration 134 122 0.000 77.770 28.587 23.75 29.28 20.7150 Pareto Statistical analysis was conducted using XLSTAT (Addinsoft) for descriptive statistics, ROC analysis, Sensitivity and Specificity analysis, calculation of positive and negative predictive value and likelihood ratios, Spearman’s correlation, and ic and nonparametric regression. Variable distributions were mapped using t re (Mathwave). Only variables that had a high area under the curve (AUC) or contributed to raising the AUC of a group of biomarkers were included in the MIRAT model. ROC analysis plots the sensitivity and specificity of the test result against each outcomemeasurement , to give an indication of a test le’s screening and/or diagnostic utility.

A cut-off point in a continuously distributed measurement delineates a normal from an abnormal result. s of sensitivity, specificity, positive and ve predictive value, and likelihood-ratio are also supplied. In this setting, a high sensitivity and PPV means that a test only rarely misses classifying a sick person as sick, in terms of the diagnosis and therefore, has utility as a diagnostic method. A high specificity finding combined with a high NPV means that a ROC test only rarely classifies a person with schizophrenia/psychosis as being free of that diagnosis, and the test therefore has y as a diagnostic exclusion, screening tool.

Imputation In some instances symptomatic participants were unable to complete all the tests in the MIRAT model testing domains. If the data already present in the domain met the cut-off requirements for the cut-off for the composite Nutrition-Biochemistry, Visual or Auditory model respectively, then the value for the domain was imputed and contributed to the score for the ‘Combined model with imputed values’. This procedure did not alter the cut-off point from the ‘Combined model’ with no imputation, and accommodates the real life scenario in which symptomatic patients may be unable to complete all tests due to cognitive or motor deficits. It is possible to apply this same method for imputing the final outcome for the MIRAT model when full data for a patient is not ble.

Clinical Validation A correlation matrix sing of spearman correlation cients was constructed to fy the onships between the domains of the MIRAT model and measures of severity (Symptom Intensity Rating (SIR) and Clinical Global Impression (CGI) and lity (GAF) and disability support pension (DSP) , and treatment resistance (number of hospital admissions).

Example 2 – MIRAT assessment of symptomatic and asymptomatic subjects er operating characteristic (ROC) analysis and odds ratio analysis was carried out on the variables described above in Example 1 as measured in the 67 selectively medicated symptomatic ts and 67 asymptomatic subjects described in Example 1.

These analyses identified a number of variables that were capable of differentiating cases from controls by demonstrating an area under the curve and other parameters of ient icance to consider them to be biomarkers. These variables were classified into five main categories (domains) and one supplementary category n).

Summarised values for a five domain model, including the five main domain, and six domain model, including these five main domain and the supplementary domain (middle ear domain), are shown in Table 2. These categories were neurotransmitters, ive stress, nutrition, visual processing, auditory processing, and measures of middle ear performance in terms of tympanic reflex and stapes muscle contraction. These ker variables were combined to form a combined multi-domain model (called MIRAT Model) of schizophrenia and -affective disorder. Table 3 details the variables selected in the MIRAT model and their statistical parameters.

Odds ratio analysis performed on summated ROC scores of the multiple ROC s in this model yielded a risk of association with a diagnosis of schizophrenia or schizoaffective er measure. Any value greater than 10 for the odds ratio is considered significant. While some variables do not meet this value individually, they nonetheless contribute significantly to the model. It is clear from the odds ratios in Table 2 that ing markers into models gives better statistical outcomes than using single markers.

Individual biomarker variables in the MIRAT model showed either high sensitivity or high specificity for the detection of schizophrenia/psychosis. Noradrenaline, adrenaline, visual span, visual speed of processing variables, competing words, auditory speed of processing variables and low peak middle ear pressure, showed both high sensitivity and high icity.

Each subcomponent of the 5 and 6 domain MIRAT Model was scored to a one or a zero using its unique cut-off value that was identified through ROC analysis. The subcomponent scores were tallied for the Domain and then the Domain was scored as a one or a zero based on its unique cut-off value that was identified h ROC analysis. s with missing subcomponent values but a sufficient ponent tally to code the Domain to one or zero were imputed. The scores for each Domain were combined (tallied) to provide a total score for the MIRAT Model. The minimum score is zero and the maximum score is five. The combined MIRAT Model score is used to identify the risk of schizophrenia/psychosis being present and/or developing in the future. Nonparametric and Log-logistic Regression models identify the risk of schizophrenia/psychosis based on a combined MIRAT Model score of 1 through to 5. A combined score of 3 or more abnormal Domains is indicative of a significant risk of sis of schizophrenia/psychosis. The Middle Ear Domain is used in borderline cases to ment the ation provided by the main ed Five Domain Model.

This process of coding and combining individual biomarkers resulting in the combined model with imputation, demonstrated a sensitivity of 73 to 93 per cent and a specificity of 80 to 96 per cent, for identification of the schizophrenia/ psychosis condition, at the 95% level of significance. The model correctly identified 43 out of 50 (86 per cent) of symptomatic participants as schizophrenia/psychosis and 59 out of 65 (91 per cent) of asymptomatic participants as no schizophrenia/psychosis. The additional use of the supplementary Middle Ear Domain enables the identification of 47 out of 49 (96 per cent) of symptomatic participants as schizophrenia/psychosis. Also, there was insignificant difference between imputed and non-imputed form of the model, as shown in Figure 1. 0.0005 0.0026 < 0.0001 0.0933 Odds Ratio P value <0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.0104 0.0009 3.64 3.24 8.5 1.89 Odds Ratio 9.60 21.25 14.32 16.47 4.12 2.60 3.75 0.001 0.001 0.001 0.186 ROC P value 1 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.022 0.002 0.12 0.39 0.10 18.56 % Risk of rejecting H0 0.01 0.01 0.01 0.01 0.01 2.19 0.17 0.997 0.996 0.997 0.998 NPV 0.997 0.999 0.999 0.9997 0.998 0.997 0.997 38 PPV 0.028 0.027 0.019 0.015 0.009 0.008 0.008 0.009 0.007 0.010 0.019 Multi-domain MIRAT ROC model (combination 5 and 6 domain model) SPEC 0.821 0.746 0.642 0.940 0.881 0.746 0.484 0.716 0.761 0.791 0.875 SENS 0.758 0.848 0.379 0.742 0.697 0.470 0.800 0.591 0.373 0.462 0.548 AUC 0.859 0.844 0.702 0.851 0.696 0.611 0.638 0.654 0.565 0.651 0.797 No.Obs 133 133 133 133 133 133 129 133 134 132 126 Neurotransmitter Domain y r t (Catecholamines) i s e m c h B i o Table 2.

ROC Variables Neurotransmitter Domain (Catecholamines) High Adrenaline High (HPL/Creatinine) Domain High Dopamine High Noradrenaline - Model Nutrition-Biochemistry Domain High Free copper to Zinc ratio Low B6 activation Low Red cell folate High Serum B12 (80 per cent) Low Vitamin D n i o t r i t N u Domain Model < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 <0.0001 < 0.0001 0.0001 < 0.0001 119.87 45.89 22.46 11.1 10.69 21.23 29.57 50.21 27.22 5.17 41.48 < 0.0001 < 0.0001 0.000 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 < 0.0001 0.01 0.01 0.02 0.01 0.01 0.01 0.01 0.01 0.01 0.010 0.998 0.999 0.999 0.999 0.999 0.999 0.999 0.999 0.999 0.997 0.999 39 0.021 0.009 0.015 0.027 0.021 0.038 0.158 0.039 0.015 0.014 0.031 0.821 0.552 0.773 0.879 0.818 0.905 0.984 0.908 - 0 9 . 8 ( 0 0.960) 0.731 0.851 0.881 0.841 0.659 0.824 (0.694 - 0.745 0.868 0.906) 0.831 0.900 0.759 0.909 0.475 0.849 0.952 0.952 0.951 0.862 0.810 0.799 0.874 0.891 0.875 0.597 0.915 126 122 128 120 127 124 121 119 107 107 116 e l Mo d a i n Visual Domain Low Visual span High Visual speed of processing discrepancy (% of age) Poor Distance vision on right Visual Domain Model Auditory Domain Low e digit span 4/8 High Competing words discrepancy (% of pass score) High Auditory speed of processing discrepancy (% of age) Auditory Domain Model o m - D Combined 5- Domain Model 3 or > 3 5 Cut off Cut off 4 or > 4 d i n e m b C o (imputed) Cut off 3 or > 3 <0.0001 0.0181 <0.0001 0.0369 0.0064 0.0099 0.0013 0.0001 0.0001 117.33 2.74 66.93 2.19 3.77 2.61 3.42 4.80 4.28 <0.0001 < 0.0001 < 0.0001 0.000 0.0674 0.003 0.001 0.001 < 0.0001 0.01 0.01 0.01 0.04 6.74 0.29 0.01 0.14 0.03 0.998 1.00 0.997 0.997 0.997 0.997 0.998 0.998 0.997 40 0.160 0.022 0.006 0.006 0.013 0.007 0.008 0.120 0.130 0.985 0.825 0.484 0.891 0.651 0.613 0.774 0.520 0.833 9 - 8 . 6 0 ( 0.892) 0.647 0.367 0.700 0.370 0.583 0.683 0.583 0.48 0.940 - 3 0 ( . 8 0 0.985) 0.951 0.603 0.617 0.580 0.626 0.657 0.659 0.738 0.954 122 116 123 124 124 123 122 120 108 l e ear pressure (90 per cent) High Threshold stapes amplitude Model d Mo E r a i n l e a d d o m Mi D - i t h projected Low old time to offset over base-length High Threshold percentage base- length over duration. Cut off 4 or > 4 Middle Ear Domain High Threshold ear canal volume 6 w pressure High Threshold gradient middle Middle Ear Domain Low Threshold peak middle ear d e ) i n d b e t m u o p C ( i m Model 0.6692 Accur acy 0.6617 0.8120 0.7970 0.7895 20 FN 41 17 10 16 24 FP 4 8 17 12 46 TP 25 49 56 50 0.4722 LR- 0.6607 0.2925 0.2030 0.2953 1.9457 LR+ 6.3447 6.2178 3.3440 4.2298 0.9979 NPV 0.9970 0.9987 0.9991 0.9987 0.0087 PPV 0.0279 0.0273 0.0149 0.0188 0.7459 41 Upper bound 0.9802 0.9401 0.8354 0.8954 Lower bound 0.8508 0.7782 0.6294 0.5217 0.7103 ic ity 0.9403 0.8806 0.8209 0.7463 0.6418 Upper bound 0.4997 0.8327 0.8452 0.9169 0.7945 Lower bound 0.2717 0.6405 0.6244 0.7403 0.5770 0.7576 Sensitiv ity 0.3788 0.7424 0.8485 0.6970 133 133 133 No Obs 133 133 Neurotransmitter Model MIRAT multi-domain model data High Dopamine High Noradrenaline High Adrenaline Domain Domain High Table 3.

ROC Variables Neurotransmitter (HPL/Creatinine) Model/ Domain Nutrition- Biochemistry 0.8254 0.8115 0.6090 0.6434 0.6541 0.5672 0.6288 0.7143 10 5 35 13 27 42 35 28 12 18 17 33 19 16 14 8 49 50 31 52 39 25 30 34 0.2065 0.1243 0.7106 0.4129 0.5710 0.8235 0.6807 0.5161 4.6370 3.3838 1.8512 1.5515 2.0837 1.5625 2.2088 4.3871 0.9991 0.9994 0.9968 0.9981 0.9974 0.9963 0.9969 0.9977 0.0205 0.0151 0.0083 0.0070 0.0093 0.0070 0.0099 0.0194 0.8954 0.8375 42 0.8354 0.6041 0.8104 0.8126 0.8718 0.9371 0.6294 0.3665 0.5981 0.6803 0.6775 0.7688 0.7103 0.6252 0.7463 0.4844 0.7164 0.7612 0.7910 0.8750 0.8209 0.7313 0.5884 0.8799 0.7011 0.4541 0.5814 0.6656 0.9065 0.9851 0.3545 0.6853 0.4703 0.4253 0.7126 0.3064 0.3461 0.8331 0.5484 0.8305 0.4697 0.8000 0.5909 0.3731 0.4615 0.9091 126 133 129 133 134 132 126 122 Nutrition- Biochemistry Domain Visual Domain High Serum B12 Low Red cell folate Domain High Free copper to Zinc ratio Low B6 activation (80 per cent) Low Vitamin D Low Visual span High Visual speed of processing discrepancy (% of age) 0.6016 0.5887 0.6719 0.8667 0.8707 0.8362 0.6810 38 18 32 8 9 18 37 11 33 10 8 6 1 0 22 42 29 45 42 33 14 0.7673 0.6194 0.6166 0.1714 0.1944 0.3585 0.7255 2.1000 1.3576 3.1852 7.1108 8.9216 42.058 8 +Inf 0.9965 0.9972 0.9972 0.9992 0.9991 0.9984 0.9967 0.0094 0.0061 0.0142 0.0311 0.0388 1.0000 0.1597 0.9007 0.6041 43 0.9182 0.8939 0.9596 1.0000 1.0000 0.7438 0.8244 0.8085 0.9084 0.9314 0.7113 0.3665 0.8507 0.8806 0.9077 0.9846 1.0000 0.8254 0.4844 0.5983 0.8670 0.9057 0.7635 0.4109 0.4936 0.8011 0.3555 0.6943 0.7822 0.5092 0.1709 0.2564 0.5739 0.4754 0.8491 0.8235 0.6471 0.2745 0.3667 0.7000 128 120 116 116 116 123 124 Combined Model Imputed* (cut-off > or = 3) Combined Model Imputed* (cut-off > or = 4) Combined Model Imputed* (cut-off > or = 5) Supplementary Middle Ear Domain High old ear canal volume Poor Distance vision on right Visual Model/Domain Low Threshold 0.6583 0.6129 0.6179 0.6475 0.6803 12 41 25 19 25 29 7 22 24 14 48 19 35 41 35 0.3871 0.7673 0.6402 0.5167 0.5382 1.6552 2.8952 1.6705 1.7653 2.5833 0.9983 0.9965 0.9971 0.9977 0.9976 0.0074 0.0129 0.0075 0.0115 0.0079 0.6381 44 0.9352 0.7566 0.8610 0.7239 0.8001 0.5270 0.6542 0.3932 0.4882 0.8906 0.6508 0.6129 0.7742 0.5167 0.4247 0.7869 0.6991 0.8825 0.6991 0.2316 0.4571 0.5568 0.4571 0.6800 0.6833 0.5833 0.8000 0.3167 0.5833 124 122 122 123 120 Low Threshold time to offset over base length High Threshold percentage base length over duration Middle Ear peak middle ear pressure High Threshold gradient middle ear pressure (90 per cent) High Threshold stapes amplitude projected Domain All values reported at 95% confidence interval unless otherwise stated.

When logistic regression is was med on summated ROC scores of the multiple ROC domains in this model, this yielded a predictive risk of schizophrenia or schizo-affective disorder or Mental Illness Risk Assessment Test ). In this Mental Illness Risk Prediction Test, percentage risk of schizophrenia diagnosis is presented in relationship to the number of MIRAT domains that were scored as ning ROC biomarker-variables that were significantly abnormal. When ic Regression was performed on summated ROC scores of the multiple ROC domains in this model, this yielded the Mental Illness Risk Assessment Test (MIRAT). In this Mental Illness Risk Prediction Test, percentage risk of schizophrenia diagnosis is ted in relationship to the number of MIRAT domains which were scored as containing ROC biomarker-variables that were significantly abnormal. The Nagelkerke R2 for the logistic model of 'Combined model (imputed)' and matic/asymptomatic status was 0.752. A non-parametric regression model was also constructed. The goodness of fit (R2) for the non-parametric regression model was 0.626. Logistic and non-parametric regression models of MIRAT are shown in Table 4.

Table 4. Predictive relationships using logistic regression and non-parametric regression Combination 5 domain Model (with imputation).

Logistic Regression Non Parametric (LOWESS) Regression Score Predicted Lower bound (%) Upper bound (%) ted risk (%) 0 0.97 0.19 4.78 0 1 6.13 2.21 15.87 3.7 2 30.32 18.30 45.81 38.88 3 74.37 56.99 86.40 66.22 4 95.08 84.28 98.59 88.48 99.23 95.16 99.88 100 *Contains imputed values for Nutrition-Biochemistry, Visual, or Auditory Domains Incorporating the supplementary Middle Ear domain reduces the number of false negatives from seven to two of the symptomatic participants. It does however increase the number of false positives from six to twelve and so should only be used when schizophrenia/psychosis is suspected but the main MIRAT model returns a negative result for schizophrenia/psychosis.

The odds ratio analysis (Table 5) demonstrates the association of the score for the number of abnormal domains with a diagnosis of schizophrenia or schizo-affective er. Odds ratio analysis still trates that abnormality of more than 3 domains of the model is significantly associated with a diagnosis of schizophrenia, affective disorder or psychosis, as described above. er this model demonstrates that abnormality in 4 domains of the model is associated with a very high risk of having these conditions (as is shown in the previous logistic regression model).

Table 5. Odds ratio: combined 5 domain model Lower bound Upper bound Number of Odds Ratio 95 % 95 % abnormal confidence confidence Standard domains TPxTN/(FPxFN) interval interval error p value 3 45.8 15.18 138.71 0.5644 < 0.0001 4 117.3 14.99 917.88 1.0495 < 0.0001 In order to cross-validate the combined model, a ation matrix comprising of Spearman correlation cients (rho) was constructed. The Combined Model (MIRAT) with imputed values, showed high level correlations with severity and disability, and treatment resistance, at the 95 per cent level of significance (Table 6).

Table 6 - Spearman rank correlations for functional outcome ratings in relationship to biomarker les and domain models.

Symptom Case intensity Multi-domain versus SOFAS GAF CGI Treatment lity Rating model l ROC ROC ROC resistance Pension (SIR) Combined 5- domain model with 0.770 0.752 0.770 0.754 0.830 0.677 0.697 imputed values Combined omain model (no 0.789 0.772 0.772 0.774 0.829 0.651 0.697 imputation) Neurotransmitter 0.598 0.591 0.562 0.591 0.583 0.460 0.467 domain 0.339 0.312 0.315 0.312 0.421 0.296 0.327 HPL/Creatinine Nutrition- Biochemistry 0.458 0.415 0.415 0.415 0.403 0.309 0.404 domain Visual domain 0.730 0.727 0.745 0.729 0.766 0.608 0.624 Auditory domain 0.650 0.632 0.618 0.636 0.608 0.530 0.583 Middle Ear domain 0.340 0.341 0.328 0.341 0.300 0.212 0.377 Combined (imputed) 0.775 0.758 0.742 0.761 0.748 0.609 0.636 6-domain model, (with middle ear domain).

All correlation coefficient (rho) values are significant at the 95 per cent level of significance. Impact of visual domain biomarkers on e functional outcomes is particularly noteworthy.

Clinical Global Impression of Severity (CGI), Global Assessment of Function (GAF), Social and Occupational Functioning Assessment Scale (SOFAS). HPL = urinary hydroxyhaemopyrrolineone.

The MIRAT multi-domain model was also applied to symptoms rated for intensity, from the Brief Psychiatric Rating Scale (BPRS) and the Positive and Negative m Scale (PANSS). Spearman correlation analysis revealed weak, moderate and strong level correlations between the individual ROC components, the ROC domains, the ROC models and the overall combined model (data not shown), forming the basis for a future ical classification system of serious mental illness states, symptoms and behaviours. An exemplary “signature” of the Spearman Rank Correlation Coefficients for the blunted affect schizophrenia symptom is shown in Table 7 (all values icant at p<0.001). Similar signatures can be generated for other symptoms of schizophrenia and schizo-affective er including, for example, hallucinations, delusions, suspiciousness, hostility and impulse control.

Table 7. Example symptom profile: for d affect, using Spearman’s correlation at 95% significance (alpha 0.05). ker ROCs Blunted Affect Rho for alpha Low Visual Span (n 126) 0.567 Low Auditory Speed of processing (% of age) (n 121) 0.548 High Noradrenaline (n 133) 0.513 Low Competing words score (% of pass score) (n 124) 0.489 Low Visual speed of processing (% of age) (n 122) 0.482 High Adrenaline (n 133) 0.441 Low Reverse Digit Span (n 128) 0.411 Long Threshold percent base-length/duration (n 122) 0.294 High Distance vision score (poor vision) on Right (n 128) 0.283 High HPL/Creatinine (n 133) 0.273 High Threshold gradient middle ear pressure (n 124) 0.264 Low n D (n 132) 0.233 Low threshold time to /base length (n 122) 0.211 High Threshold Stapes Amplitude Projected (n 123) 0.205 Low red cell folate (n 133) 0.193 Low activated vitamin B6 (n 126) 0.187 High Dopamine (n 133) 0.182 In particular, the inventor was able to find significant correlates for key symptoms and behaviours that have important implications for management in the clinical setting, including insight-and-judgement-impairment, anxiety, auditory hallucinations, depressed mood, motor hyperactivity, hypo-activity, suicidality and aggression.

Example 3 – Exemplary clinical application of the multi-domain MIRAT model and MIRAT test The ing is provided, by way of example only, as a means of employing a MIRAT test in a clinical setting.

A clinician (such as a general practitioner) registers with a dedicated MIRAT or other named website, submits their credentials, obtains t consent, and orders patient blood and urine tests. The clinician also completes a symptom check-list and undertakes a number of neuro-sensory and cognitive tests. The results of the blood and urine tests for the patient will be supplied to both the ian and a central body or authority maintaining and holding MIRAT test information, and will be entered onto the website, together with the results of the cognitive tests.

Two thms or calculations are then applied to the test s by the central body or authority g the MIRAT test information, one algorithm to provide a risk prediction score and diagnostic accuracy for the patient in which scores are obtained over several tive domains of patient-functioning on the MIRAT multi-domain model and riskprediction relies on how many abnormalities exist in each domainat a biomarker threshold level. The other algorithm or calculation is for ining risk prediction and diagnostic accuracy based upon symptom ratings using symptom rating scales comprising the Brief Psychiatric Symptom Rating Scale (BPRS) combined with the Positive and Negative Syndrome Scale (PANSS) symptom s. The clinician will then be ed with an overall outcome table, such as depicted in Tables 4 and 5 (above) and/or a risk prediction index.

In cases which do not reach old for psychosis/schizophrenia progression, or to increase the sensitivity of the test, the middle ear domainmay be employed.

Alternatively or in addition, evidence or information for an alternative diagnosis such as depression may also be supplied to the clinician.

Claims (7)

Claims

1. A method for diagnosing schizophrenia, schizo-affective er and/or psychosis in an individual or predicting risk of the individual developing schizophrenia, schizo-affective disorder or psychosis, the method comprising: (i) determining values for one or more markers in each of five s in one or more biological samples obtained from the individual: (a) a neurotransmitter domain comprising dopamine, noradrenaline and adrenaline; (b) an oxidative stress domain comprising urinary hydroxyhemopyrrolineone and urinary creatinine, and/or other marker of oxidative stress; (c) a nutrition-biochemistry domain sing free copper to zinc ratio, activated vitamin B6, red cell folate, serum vitamin B12, and vitamin D; (d) a visual processing domain comprising visual span, visual speed of processing discrepancy, visual speed of sing, and distance vision on right; and (e) an auditory sing domain comprising reverse digit span, ing words discrepancy, auditory speed of processing pancy, and auditory speed of processing; (ii) comparing values for said one or more s in each of said domains to control values of said markers in subjects not suffering from schizophrenia, schizo-affective disorder or psychosis, wherein the values of said markers indicative of schizophrenia, schizo-affective disorder or psychosis are, relative to said l values: - in the neurotransmitter domain, high dopamine, high noradrenaline, and high adrenaline; - in the oxidative stress domain, high urinary hydroxyhemopyrrolineone divided by urinary creatinine; - in the nutrition-biochemistry domain, high free copper to zinc ratio (or low zinc to free copper , low activated vitamin B6, low red cell folate, high serum vitamin B12, and low vitamin D; - in the visual processing domain, low visual span, high visual speed of processing discrepancy (percentage of age), low visual speed of processing (percentile), and poor distance vision on right; and - in the auditory processing domain, low reverse digit span, high competing words discrepancy (percentage of pass score), high auditory speed of processing discrepancy (percentage of age), and low auditory speed of sing (percentile) thereby diagnosing schizophrenia, schizo-affective disorder and/or psychosis in the individual or predicting risk of the individual developing schizophrenia, schizo-affective disorder or psychosis.

2. The method of claim 1, comprising determining values for each of said markers in each of said domains.

3. The method of claim 1 or claim 2, further comprising determining values for one or more markers in a middle ear domain sing old ear canal volume, old peak middle ear re, threshold gradient middle ear pressure, old stapes amplitude projected, threshold time to offset divided by baselength and threshold percentage baselength divided by duration, and comparing values for said one or more markers to l values of said s in subjects not suffering from schizophrenia or psychosis, wherein the values of said markers indicative of schizophrenia or psychosis are, relative to said control values, high old ear canal volume, low threshold peak middle ear pressure, high threshold gradient middle ear pressure, high threshold stapes amplitude ted, low threshold time to offset divided by baselength and high threshold percentage baselength divided by duration.

4. The method of any one of claims 1 to 3, wherein said method comprises conducting statistical analysis of determined values of said markers in combination and diagnosing schizophrenia or psychosis in said individual on the basis of ed analysis.

5. The method of any one of claims 1 to 4, wherein said statistical analysis comprises receiver operating characteristic (ROC) analysis and/or odds ratio analysis.

6. The method of claim 5, wherein said ROC analysis ses ascertaining ROC ranges for individual ROC variables and combined or summated sets of ROC variables, using an appropriate means to determine standard deviation adjusted for the position of ROC-variable-cut-off values in the bution of their variable .

7. The method of claim 5 or 6, wherein summated ROC scores of multiple ROC domains are subjected to odds-ratio analysis or logistic regression, for the purpose of determining diagnosis accuracy or risk prediction.