Redox compromise as an early, modifiable entry point in schizophrenia: a staging framework for early intervention

Schizophrenia is understood as a disorder of dopamine signaling and is treated with dopamine receptor antagonists. These drugs reduce hallucinations and delusions but leave cognitive impairment, negative symptoms and functional decline largely untouched. This article advances a complementary view, as a hypothesis rather than an established account. It treats redox compromise, meaning chronic oxidative stress, glutathione depletion, mitochondrial inefficiency and the inflammatory state that accompanies them, as an early and modifiable point of entry into a self-reinforcing loop. The loop also involves NMDA receptor hypofunction, impairment of parvalbumin interneurons, disturbed circuit connectivity and, last, the dopaminergic phenotype that current drugs address. It runs in both directions: blocking NMDA receptors itself generates oxidative stress in animal models, so the claim is not that redox compromise comes first, but that it can be measured and modified early, before the changes that current treatment cannot reverse. The clinical staging framework of McGorry and the neuroprogression framework of Berk provide the architecture for translating this into intervention windows, with the first two levels treated as risk strata rather than disease stages. Impaired glucose tolerance in first-episode patients who have never taken antipsychotics, which neither medication nor chronicity can explain, is presented as evidence that metabolic disturbance is a parallel expression of the same systemic process. The progressive framing is contested. The principal counterevidence, including the contribution of antipsychotic exposure to brain volume loss and the largely stable course of cognitive impairment after onset, is set out together with the results that would require abandoning it. We organize the biomarker literature by stage and propose three predictions that a trial could refute: that biomarker-stratified prevention will outperform unselected prevention at the clinical high-risk stage; that medial prefrontal glutathione and mismatch negativity deficit will add predictive value beyond clinical assessment; and that removing the redox measures from a multimodal panel will worsen its prediction of transition. A biomarker-stratified phase 2b trial with a formal power calculation is proposed. The human evidence supports association and biological plausibility rather than proven causal direction.