Received: 15 November 2016 | Accepted: 1 April 2017

DOI: 10.1111/bdi.12493

ORIGINAL ARTICLE

Association between the zinc finger protein 804A (ZNF804A)

gene and the risk of schizophrenia and bipolar I disorder across
diagnostic boundaries

Ji Hyun Baek1 | Kyooseob Ha2 | Yongkang Kim3 | So Yung Yang1 |

Eun-Young Cho4 | Yujin Choi4 | Seunghyong Ryu1 | Yu-Sang Lee5 |
Taesung Park3 | Kyung Sue Hong1,4

1
Department of Psychiatry, Sungkyunkwan
University School of Medicine, Samsung Objectives: In this study, we aimed to determine the role of genetic variations within
Medical Center, Seoul, Korea the zinc finger protein 804A (ZNF804A) gene, a candidate for a psychosis risk-­
2
Department of Psychiatry, Seoul National conferring gene, in the development of schizophrenia (SZ) and bipolar disorder (BP) in
University College of Medicine, Seoul, Korea
3 the Korean population.
Department of Statistics, Seoul National
University, Seoul, Korea Methods: A total of 921 patients with SZ, bipolar I (BP-­I) and II (BP-­II) disorder, and
4
Samsung Biomedical Research Institute, 502 control subjects participated in the study. Twenty-­one tag single nucleotide poly-
Samsung Medical Center, Seoul, Korea
5
morphisms (SNPs) across the genomic region of ZNF804A and seven reference SNPs
Yong-In Mental Hospital, Kyunggi-Do, Korea
based on previous reports were genotyped. We applied logistic regression analyses
Correspondence under additive, dominant and recessive models.
Kyung Sue Hong, Department of Psychiatry,
Sungkyunkwan University School of Medicine, Results: Fifteen of the 28 SNPs showed a nominally significant association with at least
Samsung Medical Center, Seoul, Korea. one diagnostic group. However, none of these associations remained significant after
Email: hongks@skku.edu
false discovery rate (FDR) correction. As the trend of association was observed mostly
Present address in SZ and BP-­I with similar patterns, we performed a post hoc analysis for the combined
Seunghyong Ryu, National Center for Mental
Health, Seoul, Korea. SZ and BP-­I group. Five SNPs (rs2369595, rs6755404, rs10931156, rs12476147 and
rs1366842) showed a significant association with an FDR-­corrected P of <.05.
Funding information
This work was supported by a grant from the Conclusions: This study supports a possible role of ZNF804A in the common suscep-
National Research Foundation of Korea (NRF) tibility of major psychoses, and identified additional candidate variants of the gene in
funded by the Korean government (MSIP)
(2015R1A2A2A01002699). The work Y. Kim the Korean population.
and T. Park was supported by the Bio-Synergy
Research Project (2013M3A9C4078158) KEYWORDS
of the Ministry of Science, ICT and Future
bipolar disorder, genetic association, psychosis, schizophrenia, zinc finger protein 804A
Planning through the National Research
Foundation. (ZNF804A)

1 | INTRODUCTION
Since the Kraepelinian dichotomy was proposed, schizophrenia (SZ)
and bipolar disorder (BP) have been regarded as two distinct diagnos-
tic entities. However, substantial overlaps in clinical features, treat-
ment modalities, and biological findings between these two conditions
have been noted.1,2 Findings from genetic studies also indicate shared
genetic susceptibilities between SZ and BP.3-5
The zinc finger protein 804A (ZNF804A) gene has received atten-
tion as a psychosis risk-­conferring gene, since a variant within this gene
(rs1344706) showed a strong association with a broader psychosis
phenotype including SZ and BP in a large-­scale multistage association
study.6 After the initial report of O’Donovan and colleagues,6 exten-
sive follow-­up studies have been conducted for SZ. Replicated asso-
ciation findings have been reported for the original reference single
nucleotide polymorphism (SNP) (rs1344706) in several independent

Bipolar Disorders. 2017;1–9. wileyonlinelibrary.com/journal/bdi © 2017 John Wiley & Sons A/S. | 1
Published by John Wiley & Sons Ltd
2 |
ethnic groups.7-14 Through investigation of further variants within this
gene, a non-­synonymous SNP (rs1366842) was also identified as a
candidate variant showing a significant association in the Asian and
UK populations.12,15-17 Association studies for SZ-­related endopheno-
types18-21 and gene expression studies9,22,23 also followed.
For BP, a smaller number of studies have been performed, and only
one or two reference SNPs were investigated. Both the original study of
O’Donovan and colleagues6 and a follow-­up fine-­mapping study12 tested
BP samples to expand the positive findings (for rs1344706) generated
from their prior scanning for SZ. Another study including both SZ and BP
patients tested rs1344706 and reported a significant association with the
combined psychosis group.11 A negative finding for BP or the combined
SZ and BP group was also reported in studies of German24 and Costa
22
Rican populations. There are two studies that specifically focused on
BP and included additional subgroup analyses. Lett and colleagues25 re-
ported a nominally significant association of rs1344706 with BP and also
with subgroups that had a lifetime experience of psychotic symptoms
or suicide attempts. More recently, selected variants were tested in the
23
Chinese population, and a significant association with rs1344706 was
observed in bipolar I disorder (BP-­I) but not in bipolar II disorder (BP-­II).
Considering the heterogeneity of the above-­mentioned studies in
terms of the diagnostic groups, ethnic groups, and genetic variants tested,
it is hard to integrate their findings in order to draw a conclusion regard-
ing the role of ZNF804A in SZ and BP crossing the diagnostic boundary.
Further investigations covering the entire genomic region of this gene
and analyzing both SZ and BP in the same study subjects are required.
In this study, we aimed to determine the role of ZNF804A in sus-
ceptibility to SZ and BP in the Korean population. We covered the ge-
nomic locus of ZNF804A with tag SNPs and reference SNPs based on
previous positive results. Considering that BP-­I and BP-­II have shown
distinct clinical characteristics and family history in our previous stud-
ies,26,27 BP-­I and BP-­II were analyzed as separate diagnostic groups.
2 | MATERIALS AND METHODS
2.1 | Study subjects
Subjects were patients who met the DSM-­IV diagnostic criteria for
SZ (n=582) and BP (n=339), including BP-­I (n=180) and BP-­II (n=159).
Patients with SZ were recruited from the Samsung Medical Center,
Yongin Mental Hospital, St. Andrew’s Hospital and Chuncheon National
Hospital; BP patients were recruited from the Samsung Medical Center
and Seoul National University Bundang Hospital. Clinical symptoms
were assessed on a lifetime basis through direct interview with patients
TABLE 1 Basic demographic characteristics of subjects
Variable Control (N=502) SZ (N=582)
Age, mean (SD) 31.6 (7.9) 33.9 (9.5)
Sex (male, %) 43.8 53.6
BP-­I, bipolar I disorder; BP-­II, bipolar II disorder; SZ, schizophrenia.
a
After post hoc analysis, the BP-­II group was older than other groups and the control group was younger than other groups. There were more male individ-
uals in the schizophrenia group than in the BP-­I and control groups, and the BP-­II group had more female individuals than the other groups.
BAEK et al.
using the Korean version of the Diagnostic Interview for Genetic
Studies,28 a semi-­structured clinical interview schedule that adopts the
DSM-­IV criteria. The control group (n=502) consisted of volunteers
from the community who were free of any history of clinically signifi-
cant psychiatric symptoms. Written informed consent was obtained
from all subjects after a complete explanation of the study. The basic
demographic characteristics of the participants are displayed in Table 1.
This study was approved by the institutional review boards at Samsung
Medical Center and Seoul National University Bundang Hospital.
2.2 | SNP selection
We used the Korean Hapmap database (http://www.khapmap.org) to se-
lect ZNF804A tag SNPs. Twenty-­one tag SNPs were chosen by the pro-
gram Tagger within Haploview v4.0 (http://www.broad.mit.edu/mpg/
haploview) using the pairwise tagging of SNPs with an r2>.8 and minor al-
lele frequency (MAF) >0.05.29,30 Four SNPs in the 5′-­untranslated region
(UTR) and introns (rs1021042, rs10497655, rs359895 and rs3931790)8-
10,12,31
and three non-­synonymous SNPs in exon 4 (rs12476147,
rs1366842 and rs3731834)10,12,16,17,22 were additionally included based
on prior reports of significant associations with SZ and/or BP (sum-
marized in Figure 1). The genomic location, allele types, and minor al-
lele frequencies are summarized in Table 2. These SNPs span the entire
ZNF804A region with an average inter-­SNP distance of 12.9 kb.
2.3 | DNA extraction and genotyping
Genomic DNA was isolated from peripheral blood leukocytes using
the Wizard Genomic DNA Purification kit according to the manufac-
turer’s instructions (Promega, Madison, WI, USA). Genotyping was
performed using the MassARRAY assay (Sequenom, San Diego, CA,
USA) or the TaqMan SNP genotyping ASSAY (Applied Biosystems,
Foster City, CA, USA).
For the twenty-­one tag SNPs, MassARRAY Assay Design version 3.0
software (Sequenom) generated two multiplex reactions, resulting in 11
SNPs for plex 1 and 10 SNPs for plex 2. Multiplex SNP genotyping was
performed by primer extension and matrix-­assisted laser desortion/ion-
ization time-­of-­flight mass spectrometry using the iPLEX Gold technol-
ogy from Sequenom. SNP assays were designed using the Sequenom
MassARRAY Assay Design version 3.0 software (primer information is
available upon request). The polymerase chain reaction (PCR) was per-
formed according to the standard iPLEX methodology. Spectra were an-
alyzed by MassARRAY Typer version 3.4 software (Sequenom). Quality
control was performed to exclude individual SNPs or samples with
BP-­I (N=180) BP-­II (N=159) Statisticsa
33.9 (10.1) 37.4 (11.4) F=16.6 P<.001
2
38.3 25.2 χ =46.2 P<.001
BAEK et al. | 3

Schwab Zhang Zhang

Huang et al. Zhang et al. Guella et Li et al. Zhang et Chen et Li et al. Williams Li et al. Lett et al. Steinberg Riley et al. O'Donovan
Study Current study et al. et al. et al.
(2016)[1] (2015)[2] al.(2014)[3] (2013)[5] al.(2012)[6] al.(2012)[7] (2012)[8] et al.(2011)[11] (2011)[11] (2011)[12] et al.(2011)[13] (2010)[14] et al.(2008)[15]
(2013)[4] (2011)a[9] (2011)b[10]

Han Han Han Han Chinese; Han Han WTCCC Han European
Population Korean Asian Costa Rican Indonesian European ICCSS WTCCC (UK)
Chinese Chinese Chinese; UK Chinese Japanese Chinese Chinese (UK) Chinese (CAMH)
BP;
Subject SZ; BP-I SZ BP-I; BP-II SZ; BP SZ SZ SZ SZ SZ SZ SZ SZ; BP SZ SZ; BP SZ SZ; BP
subgroup
Meta Meta(2) & Indivi Meta
Type of analysis Individual Meta(1) & Individual Individual Meta(2) & Individual Individual Individual Individual Individual Individual Meta(1)
(163/focused Meta (1) individual dual (12 in SZ;
(No. of SNPs) (28) individual(2) (2) (16) Individual(9) (1) (4) (6) (1) (1) (12) & GWAS
on 4 SNPs) (111) (1) 1 in BP)
SNPs SNPs on
Asian ref onseveral The Ref SNP +
Ref SNP + Functional Ref SNP
Type of selected SNP Tag SNP SNP +Asian Ref SNP Ref SNP Ref SNP Ref SNP Ref SNP Chipsincludi Ref SNP conserved tag SNP Ref SNP Ref SNP GWAS
exonic SNP tag SNP +tag SNP
GWAS ng mammalian onpromoter
GWAS region ofgene
185453158 5'-utr rs1021042 rs1021042 rs1021042
185460295 5'-utr rs11888068 rs11888068
185460842 5'-utr rs13026173 rs13026173
185462041 5'-utr rs10497655 rs10497655 rs10497655
185463185 5'-utr rs359895 rs359895 rs359895 rs359895 rs359895m rs359895
Exon 1
185477677 intron 1 rs13393273 rs13393273
185480633 intron 1 rs1427150
185483108 intron 1 rs17508595 rs17508595
185483858 intron 1 rs359882
185489221 intron 1 rs12613195 rs12613195 rs12613195S rs12613195
185489430 intron 1 rs17617468
185507229 intron 1 rs12693385
185526003 intron 1 rs899846
185533580 intron 1 rs7597593 rs7597593 rs7597593 rs7597593
185547462 intron 1 rs1480481 rs1480481
185552092 intron 1 rs17584193
185681730 intron 1 rs17584522S
185599568 intron 1 rs2170202
185609004 intron 1 rs2170203S+BP-I
185626426 intron 1 rs2369595S+BP-I
185638875 intron 1 rs17617913
185647985 intron 1 rs17584494
185680799 intron 1 rs10201360
185705856 intron 1 rs7605689
Exon 2
185763376 intron 2 rs3931790 rs3931790 rs3931790S rs3931790
185766816 intron 2 rs7603001
185767854 intron 2 rs1366840S+BP-I
185769921 intron 2 rs10497662
185771745 intron 2 rs4666994
185778428 intron 2 rs1344706 rs1344706 rs1344706m;BP-I rs1344706 rs1344706 rs1344706m rs1344706 rs1344706m rs1344706 rs1344706 rs1344706S,BP rs1344706 rs1344706 rs1344706S,BP rs1344706 rs1344706m;S, S+BP
185780221 intron 2 rs4666998
185780225 intron 2 rs13423388
185780306 intron 2 rs56280129
185782312 intron 2 rs7593816
185783141 intron 2 rs1583048 rs1583048 rs1583048S
185785947 intron 2 rs2059924
185796842 intron 2 rs6726421S
185797228 intron 2 rs6755404S+BP-I
185797687 intron 2 rs10931156S+BP-I
Exon 3
rs4667000
185800905 exon 4 rs12476147S+BP-I rs12476147S rs12476147 rs12476147S
185801559 exon 4 rs37676856S
185801597 exon 4 rs61739290 rs61739290S
185801747 exon 4 rs4667001S rs4667001
185801756 exon 4 rs61739288
Exon 4 185802243 exon 4 rs1366842S+BP-I rs1366842 rs1366842 rs1366842m rs1366842S
185802335 exon 4 rs79776875
185802363 exon 4 rs12477430 rs12477430
185802858 exon 4 rs78816540
185803127 exon 4 rs79082132
185803364 exon 4 rs3731834 rs3731834 rs3731834S
185804581 rs62198467

F I G U R E 1 Relative positions of the zinc finger protein 804A (ZNF804A) single nucleotide polymorphisms (SNPs) analyzed in the current
study and previous studies reporting positive associations with schizophrenia or bipolar disorder. Relative positions of the exons are displayed
in the left column. BP, bipolar disorder; BP-­I, bipolar I disorder; BP-­II, bipolar II disorder; SZ, schizophrenia. SAssociated with schizophrenia;
BP
associated with bipolar disorder; S + BP-Iassociated with the schizophrenia and bipolar disorder combined group; msignificant only in the meta-
analysis. SNPs with red letters indicate a significant association with schizophrenia and/or bipolar disorder in the corresponding study. The
green-­colored area represents the genetic loci covered with tag SNPs in the corresponding study. The box with a bold outline indicates the high
linkage disequilibrium block (D’>0.9) generated by Haploview v4.0 (http://www.broad.mit.edu/mpg/haploviewwileyonlinelibrary.com]) using the
control group data (N=502)

genotype call rates <95% and SNP assays with poor-­quality spectra/ Gold® DNA polymerase from TaqMan Universal PCR Master Mix
cluster plots. All SNPs were genotyped with call rates >98%. (Applied Biosystems). Electrophoresis was performed using the Real-­
To confirm the reliability of the iPLEX SNP genotyping method, Time PCR System (Applied Biosystems) and genotypes were determined
five selected SNPs (rs2170202, rs2170203, rs2369595, rs1366840, by measuring the fluorescence yield from each sample using Sequence
and rs6755404) for 48 random samples were re-­genotyped by per- Detection System (SDS) software (Applied Biosystems). Quality control
forming a sequencing reaction using ABI PRISM BigDye Terminator ver- was performed to exclude individual SNPs or samples with genotype call
sion 3.1 Cycle Sequencing Kits (Applied Biosystems, Foster City, CA, rates <95%. All SNPs were typed with call rates >98%.
USA). The concordance rate of genotyping data between sequencing
and iPLEX SNP genotyping was 99.6%.
2.4 | Statistical analyses
The seven reference-­based SNPs were analyzed using the TaqMan
SNP genotyping assay. Primers were designed using Primer Express ver- We used the Kruskal–Wallis test or the chi-­square test to reveal dif-
sion 3.0.1 (Applied Biosystems) and PCR was performed using AmpliTaq ferences in demographic variables among the patient and control
4 | BAEK et al.

TABLE 2 Characteristics of single nucleotide polymorphisms (SNPs) in zinc finger protein 804A (ZNF804A) analyzed in the study

SNP Genomic location Intragenic location SNP type Alleles Minor allele MAFa

rs1021042 Chr2:185453158 5′-­UTR Ref C/G C 0.265

rs10497655 Chr2:185462041 5′-­UTR Ref C/T T 0.488
rs359895 Chr2:185463185 5′-­UTR Ref A/T A 0.150
rs1427150 Chr2:185480633 Intron 1 Tag T/C C 0.133
rs359882 Chr2:185483858 Intron 1 Tag A/G A 0.169
rs12613195 Chr2:185489221 Intron 1 Tag C/G C 0.482
rs17617468 Chr2:185489430 Intron 1 Tag C/T T 0.332
rs899846 Chr2:185526003 Intron 1 Tag T/C T 0.327
rs7597593 Chr2:185533580 Intron 1 Tag T/C T 0.412
rs1480481 Chr2:185547462 Intron 1 Tag C/T C 0.168
rs17584193 Chr2:185552092 Intron 1 Tag A/G G 0.251
rs2170202 Chr2:185599568 Intron 1 Tag G/C C 0.110
rs2170203 Chr2:185609004 Intron 1 Tag T/C T 0.140
rs2369595 Chr2:185626426 Intron 1 Tag T/C C 0.108
rs17617913 Chr2:185638875 Intron 1 Tag T/C C 0.314
rs17584494 Chr2:185647985 Intron 1 Tag G/A A 0.265
rs10201360 Chr2:185680799 Intron 1 Tag C/T C 0.056
rs3931790 Chr2:185763376 Intron 2 Ref G/T C 0.322
rs1366840 Chr2:185767854 Intron 2 Tag G/A G 0.146
rs10497662 Chr2:185769921 Intron 2 Tag T/C C 0.103
rs4666994 Chr2:185771745 Intron 2 Tag A/G G 0.112
rs1344706 Chr2:185778428 Intron 2 Tag T/G T 0.444
rs1583048 Chr2:185783141 Intron 2 Tag A/G G 0.312
rs6755404 Chr2:185797228 Intron 2 Tag C/A A 0.081
rs10931156 Chr2:185797687 Intron 2 Tag G/A G 0.121
rs12476147 Chr2:185800905 Exon 4/non-­synonymous Ref A/T A 0.119
rs1366842 Chr2:185802243 Exon 4/non-­synonymous Ref G/T G 0.119
rs3731834 Chr2:185803364 Exon 4/non-­synonymous Ref C/G G 0.235

MAF, minor allele frequency; SNP, single nucleotide polymorphism; ref, reference SNP; tag, tag SNP; UTR, untranslated region.
a
Minor allele frequency based on the control group data.

groups. The Hardy−Weinberg equilibrium was checked with Fisher’s
exact test for genetic analysis, and no significant deviation was ob-
served in any of the SNPs. Genotype-­wise association was evaluated
by logistic regression analysis with age and sex as covariates. Additive,
dominant, and recessive genetic models were considered based on
the minor allele of each SNP. The inheritance model with the lowest
Akaike information criterion32 was accepted as the best fitting model.
We controlled the experiment-­wise type I error using false discov-
ery rate (FDR) correction. All statistical analyses were performed with
SNP stats ver. 1.18.0 in R ver. 3.0.2 (http://www.bioconductor.org).33
association with SZ (the lowest P-­value was .008 in rs 17617468). In
BP-­I, 12 SNPs revealed an association with nominal significance (the
lowest P-value was .003 in rs2369595). rs2369595 and five SNPs lo-
cated at the end of intron 2 and in exon 4 (rs6755404, rs10931156,
rs12476147, rs1366842 and rs3731834) showed a nominal associa-
tion with both the SZ and BP-­I groups. For BP-­II, two SNPs showed
a weak association signal with the lowest nominal P-­value of .019
in rs10497662. However, none of these associations with individual
diagnostic groups remained significant after FDR correction.

3.2 | Analyses for the combined group of SZ and

3 | RESULTS
3.1 | Analyses for individual diagnostic groups
The results of the association analyses for each diagnostic group are sum-
marized in Table 3. A total of eight SNPs showed a nominally significant
BP-­I
Figure 2 displays the association pattern between the ZNF804A SNPs
and disease groups under the additive model with a log-­transformed
nominal P-­value. For SNPs at the end of intron 2 and in exon 4 in
particular, as similar association patterns were observed for SZ and
TABLE 3 Single nucleotide polymorphism (SNP) genotype effects on schizophrenia, bipolar disorders and the combined group of schizophrenia and bipolar I disorder
BAEK et al.

Comparison with control group (N=502)

SZ (N=582) BP-­I (N=180) BP-­II (N=159) SZ + BP-­I (N=762)

Best fit Best fit Best fit

SNP Pa OR 95% CI modelb Pa OR 95% CI modelb Pa OR 95% CI modelb Pa OR 95% CI Best fit modelb

rs1021042 .859 0.978 0.766-­1.249 D .516 1.090 0.840-­1.416 A .200 0.822 0.609-­1.109 A .766 1.063 0.712-­1.586 R
rs10497655 .302 0.915 0.772-­1.083 A .407 1.179 0.798-­1.743 R .435 0.833 0.527-­1.318 R .546 0.924 0.716-­1.194 D
rs359895 .049 2.422 1.003-5.850 R .052 1.394 0.997-­1.949 A .489 1.672 0.389-­7.179 R .068 2.221 0.943-­5.233 R
rs1427150 .213 2.109 0.651-­6.831 R .031 1.510 1.039-2.196 D .203 2.855 0.567-­14.363 R .251 1.950 0.623-­6.102 R
rs359882 .421 1.325 0.668-­2.628 R .014 1.479 1.082-2.021 A .493 1.135 0.790-­1.631 A .156 1.166 0.943-­1.441 A
rs12613195 .637 1.068 0.813-­1.403 D .301 1.134 0.893-­1.440 A .325 0.793 0.499-­1.259 R .512 1.090 0.843-­1.408 D
rs17617468 .008 0.590 0.399-0.870 R .379 1.236 0.771-­1.983 R .532 0.835 0.475-­1.468 R .065 0.722 0.510-­1.021 R
rs899846 .180 0.766 0.518-­1.131 R .195 0.679 0.378-­1.220 R .050 0.507 0.257-­1.001 R .115 0.745 0.517-­1.074 R
rs7597593 .653 0.927 0.665-­1.292 R .305 0.768 0.463-­1.273 R .689 0.896 0.525-­1.530 R .462 0.889 0.649-­1.217 R
rs1480481 .336 1.116 0.892-­1.397 A .023 1.441 1.051-1.977 A .182 1.271 0.893-­1.810 A .126 1.180 0.955-­1.458 A
rs17584193 .239 0.860 0.669-­1.105 D .147 1.237 0.928-­1.649 A .222 1.268 0.866-­1.856 D .542 1.171 0.705-­1.944 R
rs2170202 .088 3.074 0.847-­ R .007 1.708 1.159-2.519 D .239 3.021 0.479-­19.038 R .036 1.312 1.018-1.692 A
11.151
rs2170203 .068 1.247 0.984-­1.580 A .024 1.465 1.051-2.043 A .137 1.323 0.915-­1.913 A .028 1.287 1.028-1.610 A
*
rs2369595 .042 1.319 1.010-1.723 A .003 1.817 1.233-2.676 D .229 3.097 0.491-­19.527 R .008 1.408 1.092-1.816 A
rs17617913 .208 1.305 0.862-­1.977 R .065 0.766 0.578-­1.017 A .405 1.315 0.691-­2.504 R .182 0.855 0.680-­1.076 D
rs17584494 .941 0.981 0.600-­1.607 R .212 0.799 0.563-­1.136 D .419 0.720 0.324-­1.598 R .705 0.957 0.760-­1.204 D
rs10201360 .332 0.322 0.033-­3.168 R .881 0.959 0.555-­1.657 A .500 2.198 0.223-­21.709 R .238 0.254 0.026-­2.476 R
rs3931790 .893 1.028 0.684-­1.545 R .501 0.888 0.629-­1.255 D .488 1.235 0.680-­2.241 R .709 1.075 0.734-­1.575 R
rs1366840 .145 1.191 0.942-­1.505 A .005 1.576 1.145-2.168 A .276 1.227 0.849-­1.773 A .030 1.276 1.024-1.592 A
rs10497662 .247 0.478 0.137-­1.666 R .442 0.437 0.053-­3.604 R .019 1.683 1.089-2.600 D .214 0.478 0.149-­1.531 R
rs4666994 .123 3.376 0.719-­ R .061 1.461 0.982-­2.173 D .172 4.060 0.544-­30.289 R .135 1.219 0.940-­1.581 A
15.866
rs1344706 .102 1.287 0.951-­1.741 R .403 1.204 0.779-­1.861 R .422 0.847 0.565-­1.270 D .108 1.265 0.950-­1.685 R
rs1583048 .682 0.914 0.596-­1.403 R .207 0.800 0.565-­1.132 D .772 1.098 0.583-­2.067 R .480 0.938 0.785-­1.121 A
rs6755404 .012 1.468 1.071-2.010 D .017 1.652 1.093-2.496 A .039 10.728 1.125- R .005* 1.504 1.128-2.005 A
102.279
rs10931156 .023 1.338 1.041-1.720 A .012 1.548 1.102-2.175 A .074 1.401 0.968-­2.029 A .008* 1.376 1.085-1.744 A
*
rs12476147 .011 1.383 1.077-1.777 A .011 1.555 1.108-2.182 A .060 2.864 0.957-­8.574 R .004 1.412 1.115-1.788 A

(Continues)
|
5
6 | BAEK et al.

BP-I, we merged these two groups and performed the same asso-

Best fit modelb

ciation analysis (Table 3). SNPs rs2369595, rs6755404, rs10931156,
rs12476147 and rs1366842 showed a significant association with this
combined group with FDR-­corrected P-values of <.05. The last four

A
R
of these SNPs are located within the same high linkage disequilibrium
(LD) block (D’>0.9) spanning the region from intron 2 to exon 4 of the

1.120-1.799
1.154-3.177
gene (Figure 1).

95% CI

A, additive; BP-­I, bipolar I disorder; BP-­II, bipolar II disorder; CI, confidence interval; D, dominant; OR, odds ratio; R, recessive; SNP, single nucleotide polymorphism; SZ, schizophrenia.
SZ + BP-­I (N=762)

1.420 4 | DISCUSSION
1.915
OR

Our findings add to the extensive literature attesting to the role of

.004*
.012

genetic variants within ZNF804A in the susceptibility to psychosis.

Pa

Unlike previous studies that began with intensive screening of an SZ

sample and only later included a BP sample to confirm the associa-
Best fit
modelb

tion observed with SZ, we included both SZ and BP populations from

A
R

the beginning and evaluated the effects of the SNPs within the whole
genomic locus of ZNF804A.
0.972-­2.032
0.625-­3.083

It is notable that association patterns in SZ and BP-­I were simi-

95% CI

lar. As a result, although none of the associations with an individual

diagnosis survived after multiple testing corrections, associations of
five SNPs (rs2369595, rs6755404, rs10931156, rs12476147 and
BP-­II (N=159)

1.406
1.389

rs1366842) remained significant in the SZ and BP-­I combined group

OR

after the FDR corrections. Of these SNPs, four SNPs are located in
the same high-­LD block (D’>0.9) spanning the region from intron 2
.070
.420
Pa

to exon 4 (Figure 1). A number of SNPs within this block showed as-
The inheritance model with the lowest Akaike information criterion was accepted as the best fitting model.

sociations with SZ in the early meta-­analysis of Williams et al.12 Also,

Best fit

SNP rs12476147 at exon 4 showed a significant association with SZ in

modelb

the Costa Rican population22 and rs1366842 revealed an association

A
R

with SZ in the meta-­analysis of Asian populations.15 The risk alleles of

1.133-2.228
1.231-4.641

these SNPs in prior studies are identical to ours (rs12476147:A and

Bold indicates nominal P<.05; *corrected P<.05 by false discovery rate (FDR) correction.
95% CI

rs1366842:G). In BP, however, effects of these SNPs have never been

examined previously.
The SNP of rs1344706, which showed the strongest association
1.589
2.390
BP-­I (N=180)

with psychosis in Western populations, did not show an association

OR

with any diagnostic group in our study. Previous studies of Chinese

Nominal P-­value by logistic regression with age and sex covariates.

or Japanese SZ patients also did not find any significant association

.007
.010
Pa

with this SNP.8,16,31 This may be due to the heterogeneity of LD

structures or risk variants between different ethnic groups.8,16,31
Best fit
modelb

Yet, considering that the recent meta-­analysis of Asian popula-

A
R

tions reported an association between rs1344706 and SZ that was

weaker than that in Western populations but still significant,15 fur-
1.074-1.777
1.037-3.025

ther analyses in the Asian population with larger sample sizes are
Comparison with control group (N=502)

95% CI

warranted.
In our study, associations with genetic variants of ZNF804A were
higher in the SZ and BP-­I combined group compared to the individual
1.382
1.771
OR
SZ (N=582)
(Continued)

diagnostic groups. This corroborates the findings of previous reports

and supports the hypothesis that ZNF804A functions as a psychosis
.012
.036

risk-­conferring gene that crosses diagnostic boundaries.34 SZ and BP

Pa

have been regarded as separate illnesses since Kraepelin’s description;

TABLE 3

rs1366842
rs3731834

however, the hypothesis of unitary psychosis has also re-­emerged

based on the clinical, biological and therapeutic overlaps between the
SNP

two diseases.35
b
a
BAEK et al. | 7

3
SZ+BP-I BP-I
SZ BP-II
2.5

1.5

1
F I G U R E 2 Association pattern between
the zinc finger protein 804A (ZNF804A)
single nucleotide polymorphisms (SNPs)
and schizophrenia and bipolar disorder 0.5
under the additive model. The log of
P-­values is represented on the y-­axis
with the relative locations of the SNPs 0
in the gene on the x-­axis. BP-­I, bipolar
rs10497655
rs359895

rs359882
rs12613195
rs17617468
rs899846

rs17584193

rs17617913
rs17584494
rs10201360

rs10497662

rs10931156
rs12476147
rs1021042

rs1427150

rs7597593
rs1480481

rs2170202
rs2170203
rs2369595

rs3931790
rs1366840

rs4666994
rs1344706
rs1583048
rs6755404

rs1366842
rs3731834
I disorder; BP-­II, bipolar II disorder; SZ,
schizophrenia

ZNF804A might contribute to the development of co-­occurring
symptoms of SZ and BP-­I. We additionally examined the effects of
ZNF804A variants (five SNPs which showed significant associations
with the combined SZ and BP-­I group) on the presence of delusions
and hallucinations, the most prominent co-­occuring psychotic symp-
toms of SZ and BP (detailed data not shown). The degree of associa-
tion (odds ratio) was not higher in patient subgroups with delusions
(1.4−1.5) and hallucinations (1.3−1.4) compared to the total SZ + BP-­I
patient group (1.4−1.5). Few studies have explored the effect of genetic
variation of ZNF804A on psychotic symptoms. Lett et al.25 reported a
stronger signal in rs1344706 with psychotic BP and Stefanis et al.21
also reported significant associations between genotypes (rs7597593,
rs1344706, rs4667001 and rs3731834) and paranoid tendency in
healthy subjects. In contrast, Xiao et al.36 reported no significant as-
sociation between positive symptoms and genotypes (rs1344706,
rs35676856, rs728534, rs4667001, rs4667002 and rs61739288) in
subjects with SZ. Since detailed symptom characteristics of all subjects
were not available, we could not conclude whether the presence of
psychotic symptoms mediated the effects of ZNF804A on the diag-
nostic groups. Further study of larger populations with more detailed
phenotypic information is needed to confirm these findings.
Unlike BP-­I, BP-­II did not show any conclusive association with
variants of ZNF804A in our study. According to DSM,37 BP-­I and BP-­
II have the same diagnostic criteria and only differ by the severity of
mania and hypomania. But studies have shown that these two dis-
orders have distinct clinical courses and treatment responses.27,38-42
Family studies also showed distinct familial aggregation patterns
and a lack of cross-­transmission between the two diseases.43,44
According to a previous study from our group, the ST8 alpha-­N-­
acetyl-­neuraminide alpha-­2, 8-­sicalyltransferase 2 gene (ST8SIA2),
another candidate for a psychosis-­conferring gene, also showed an
association with the combined SZ and BP-­I group and not with BP-­
II.45 There has been a suggestion that the genetic architecture of
BP-­II lies between that of BP-­I and major depressive disorder, while
the architecture of schizoaffective disorder is located between that
of schizophrenia and BP-­I.46 Our findings add evidence to suggest
that there are somewhat distinct genetic mechanisms for BP-­I and
BP-­II.
ZNF804A is located at 2q32.1 and is composed of four exons
while its exact function remains unknown. The effects of the SNPs
that showed associations in our study on ZNF804A expression have
also never been studied before. A postmortem gene expression study
showed that ZNF804A was expressed mainly in pyramidal cells and
was highly expressed during the fetal period.47-49 A gene expression
study with human progenitor cells showed that the knockdown of the
ZNF804A gene impacted on the expression of genes related to cell
adhesion,50 which can affect neural migration, neurite outgrowth and
synaptic formation, suggesting its potential role in the early brain de-
velopment process. Another recent study showed that expression lev-
els of ZNF804A directly modulate transcription levels of dopamine D2
receptor (DRD2) and catechol-­O-­methyltransferase (COMT) GENES.51
Further study is needed to confirm the exact role of the risk variants
of ZNF804A.
The limitations of the current study are as follows. First, the sam-
ple size, particularly for BP-­II, might not have been large enough to
detect associations. However, the negative result for BP-­II in our
study does not seem to be a false negative considering that genotype
effects of BP-­II showed the same direction but had a smaller beta
coefficient with larger variance compared to those of BP-­I (data not
shown). Second, the association of the combined SZ and BP-­I group
8 |
might have arisen from the common factors observed in both dis-
eases. We tried to investigate psychotic symptoms as possible medi-
ating phenotypes, but we were not able to examine other common
clinical or biological factors. Third, to delineate the effects of SNPs
on psychotic symptoms more clearly, BP-­I patients without psychotic
symptoms and BP-­II paitents with psychotic symptoms should be
also analyzed. Those subgroup analyses could not be performed be-
cause of the very limited sample sizes. Further studies with a much
higher number of clinically well-­evaluated subjects are warranted.
In conclusion, this study adds additional evidence that ge-
netic variants in ZNF804A are associated with susceptibility to
both SZ and BP-­I beyond the boundary of diagnosis. Future tri-
als analyzing broader psychosis categories and symptom-based
dimensions as phenotypes will help further interpretation of the
current findings.
D ISCLOSURE S
The authors have declared that there are no conflicts of interest in
relation to the subject of this study.
REFERENCES
1. Craddock N, Owen MJ. The beginning of the end for the Kraepelinian
dichotomy. Br J Psychiatry. 2005;186:364‐366.
2. Leboyer M, Schurhoff F. Searching across diagnostic boundaries.
Schizophr Bull. 2014;40:946‐948.
3. Craddock N, O’Donovan MC, Owen MJ. Psychosis genetics: modeling
the relationship between schizophrenia, bipolar disorder, and mixed
(or “schizoaffective”) psychoses. Schizophr Bull. 2009;35:482‐490.
4. Fiorentino A, O’Brien NL, Sharp SI, Curtis D, Bass NJ, McQuillin A.
Genetic variation in the miR-­708 gene and its binding targets in bipo-
lar disorder. Bipolar Disord. 2016;18:650‐656.
5. Gonzalez S, Gupta J, Villa E, et al. Replication of genome-­wide asso-
ciation study (GWAS) susceptibility loci in a Latino bipolar disorder
cohort. Bipolar Disord. 2016;18:520‐527.
6. O’Donovan MC, Craddock N, Norton N, et al. Identification of loci
associated with schizophrenia by genome-­wide association and fol-
low-­up. Nat Genet. 2008;40:1053‐1055.
7. Chen M, Xu Z, Zhai J, et al. Evidence of IQ-­modulated association be-
tween ZNF804A gene polymorphism and cognitive function in schizo-
phrenia patients. Neuropsychopharmacology. 2012;37:1572‐1578.
8. Li M, Shi CJ, Shi YY, et al. ZNF804A and schizophrenia susceptibil-
ity in Asian populations. Am J Med Genet B Neuropsychiatr Genet.
2012;159B:794‐802.
9. Riley B, Thiselton D, Maher BS, et al. Replication of association be-
tween schizophrenia and ZNF804A in the Irish Case-­Control Study of
Schizophrenia sample. Mol Psychiatry. 2010;15:29‐37.
10. Schwab SG, Kusumawardhani AA, Dai N, et al. Association of
rs1344706 in the ZNF804A gene with schizophrenia in a case/control
sample from Indonesia. Schizophr Res. 2013;147:46‐52.
11. Steinberg S, Mors O, Borglum AD, et al. Expanding the range of
ZNF804A variants conferring risk of psychosis. Mol Psychiatry.
2011;16:59‐66.
12. Williams HJ, Norton N, Dwyer S, et al. Fine mapping of ZNF804A and
genome-­wide significant evidence for its involvement in schizophre-
nia and bipolar disorder. Mol Psychiatry. 2011;16:429‐441.
13. Zhang R, Lu SM, Qiu C, et al. Population-­based and family-­based asso-
ciation studies of ZNF804A locus and schizophrenia. Mol Psychiatry.
2011;16:360‐361.
BAEK et al.
14. Zhang R, Valenzuela RK, Lu S, et al. Is the conserved mammalian re-
gion of ZNF804A locus associated with schizophrenia? A population-­
based genetics analysis Schizophr Res. 2011;133:159‐164.
15. Huang L, Ohi K, Chang H, et al. A comprehensive meta-­analysis of
ZNF804A SNPs in the risk of schizophrenia among Asian populations.
Am J Med Genet B Neuropsychiatr Genet. 2016;171:437‐446.
16. Li M, Zhang H, Luo XJ, et al. Meta-­analysis indicates that the
European GWAS-­identified risk SNP rs1344706 within ZNF804A is
not associated with schizophrenia in Han Chinese population. PLoS
ONE. 2013;8:e65780.
17. Zhang R, Yan JD, Valenzuela RK, et al. Further evidence for the associ-
ation of genetic variants of ZNF804A with schizophrenia and a meta-­
analysis for genome-­wide significance variant rs1344706. Schizophr
Res. 2012;141:40‐47.
18. Walters JT, Corvin A, Owen MJ, et al. Psychosis susceptibility gene
ZNF804A and cognitive performance in schizophrenia. Arch Gen
Psychiatry. 2010;67:692‐700.
19. Rasetti R, Sambataro F, Chen Q, Callicott JH, Mattay VS, Weinberger
DR. Altered cortical network dynamics: a potential intermediate phe-
notype for schizophrenia and association with ZNF804A. Arch Gen
Psychiatry. 2011;68:1207‐1217.
20. Yasuda Y, Hashimoto R, Ohi K, et al. Impact on schizotypal personality
trait of a genome-­wide supported psychosis variant of the ZNF804A
gene. Neurosci Lett. 2011;495:216‐220.
21. Stefanis NC, Hatzimanolis A, Avramopoulos D, et al. Variation in psy-
chosis gene ZNF804A is associated with a refined schizotypy phe-
notype but not neurocognitive performance in a large young male
population. Schizophr Bull. 2013;39:1252‐1260.
22. Guella I, Sequeira A, Rollins B, et al. Evidence of allelic imbalance in
the schizophrenia susceptibility gene ZNF804A in human dorsolateral
prefrontal cortex. Schizophr Res. 2014;152:111‐116.
23. Zhang C, Wang Z, Hong W, Wu Z, Peng D, Fang Y. ZNF804A
genetic variation confers risk to bipolar disorder. Mol Neurobiol.
2016;53:2936‐2943.
24. Schanze D, Ekici AB, Gawlik M, Pfuhlmann B, Reis A, Stober G.
Evaluation of risk loci for schizophrenia derived from genome-­wide
association studies in a German population. Am J Med Genet B
Neuropsychiatr Genet. 2011;156:198‐203.
25. Lett TA, Zai CC, Tiwari AK, et al. ANK3, CACNA1C and ZNF804A
gene variants in bipolar disorders and psychosis subphenotype. World
J Biol Psychiatry. 2011;12:392‐397.
26. Baek JH, Kim JS, Kim MJ, et al. Lifetime characteristics of evening-­
preference and irregular bed-­rise time are associated with lifetime seasonal
variation of mood and behavior: comparison between individuals with
bipolar disorder and healthy controls. Behav Sleep Med. 2016;14:155‐168.
27. Baek JH, Park DY, Choi J, et al. Differences between bipolar I and
bipolar II disorders in clinical features, comorbidity, and family history.
J Affect Disord. 2011;131:59‐67.
28. Joo EJ, Joo YH, Hong JP, et al. Korean version of the diagnostic in-
terview for genetic studies: validity and reliability. Compr Psychiatry.
2004;45:225‐229.
29. Barrett JC, Fry B, Maller J, Daly MJ. Haploview: analysis and visualiza-
tion of LD and haplotype maps. Bioinformatics. 2005;21:263‐265.
30. de BP, Yelensky R, Pe’er I, Gabriel SB, Daly MJ, Altshuler D. Efficiency
and power in genetic association studies. Nat Genet. 2005;37:
1217‐1223.
31. Li M, Luo XJ, Xiao X, et al. Allelic differences between Han Chinese
and Europeans for functional variants in ZNF804A and their associa-
tion with schizophrenia. Am J Psychiatry. 2011;168:1318‐1325.
32. Akaike H. A new look at the statistical model identification. IEEE Trans
Autom Control. 1974;19:716‐723.
33. Clayton D. snpStats: SnpMatrix and XSnpMatrix classes and methods.
R package version 1.18.0. 2014.
34. O’Donovan MC, Craddock NJ, Owen MJ. Genetics of psychosis; in-
sights from views across the genome. Hum Genet. 2009;126:3‐12.
BAEK et al.
35. Moller HJ. Bipolar disorder and schizophrenia: distinct illnesses or a
continuum? J Clin Psychiatry. 2003;64(Suppl 6):23‐27; discussion 28.
36. Xiao B, Li W, Zhang H, et al. To the editor: association of ZNF804A
polymorphisms with schizophrenia and antipsychotic drug efficacy in
a Chinese Han population. Psychiatry Res. 2011;190:379‐381.
37. American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Arlington, VA:
American Psychiatric Publishing; 2000.
38. Kim JS, Ha TH, Chang JS, et al. Seasonality and its distinct clinical
correlates in bipolar II disorder. Psychiatry Res. 2015;225:540‐544.
39. Judd LL, Schettler PJ, Akiskal HS, et al. Long-­term symptomatic sta-
tus of bipolar I vs. bipolar II disorders. Int J Neuropsychopharmacol.
2003;6:127‐137.
40. Judd LL, Akiskal HS, Schettler PJ, et al. The comparative clinical
phenotype and long term longitudinal episode course of bipolar
I and II: a clinical spectrum or distinct disorders? J Affect Disord.
2003;73:19‐32.
41. Choi J, Baek JH, Noh J, et al. Association of seasonality and premen-
strual symptoms in bipolar I and bipolar II disorders. J Affect Disord.
2011;129:313‐316.
42. Baek JH, Kim JS, Kim MJ, et al. Lifetime characteristics of evening-­
preference and irregular bed-­rise time are associated with lifetime
seasonal variation of mood and behavior: comparison between indi-
viduals with bipolar disorder and healthy controls. Behav Sleep Med.
2016;14:155‐168.
43. Merikangas KR, Cui L, Heaton L, et al. Independence of familial trans-
mission of mania and depression: results of the NIMH family study of
affective spectrum disorders. Mol Psychiatry. 2014;19:214‐219.
44. Vandeleur CL, Merikangas KR, Strippoli MP, Castelao E, Preisig M.
Specificity of psychosis, mania and major depression in a contempo-
rary family study. Mol Psychiatry. 2014;19:209‐213.
| 9
45. Yang SY, Huh IS, Baek JH, et al. Association between ST8SIA2 and the
risk of schizophrenia and bipolar I disorder across diagnostic bound-
aries. PLoS ONE. 2015;10:e0139413.
46. Craddock N, Owen MJ. The Kraepelinian dichotomy – going, going…
but still not gone. Br J Psychiatry. 2010;196:92‐95.
47. Bernstein HG, Steiner J, Dobrowolny H, Bogerts B. ZNF804A protein
is widely expressed in human brain neurons: possible implications on
normal brain structure and pathomorphologic changes in schizophre-
nia. Schizophr Bull. 2014;40:499‐500.
48. Hill MJ, Bray NJ. Evidence that schizophrenia risk variation in the
ZNF804A gene exerts its effects during fetal brain development. Am
J Psychiatry. 2012;169:1301‐1308.
49. Tao R, Cousijn H, Jaffe AE, et al. Expression of ZNF804A in human
brain and alterations in schizophrenia, bipolar disorder, and major de-
pressive disorder: a novel transcript fetally regulated by the psycho-
sis risk variant rs1344706. JAMA Psychiatry. 2014;71:1112‐1120.
50. Hill MJ, Jeffries AR, Dobson RJ, Price J, Bray NJ. Knockdown of the
psychosis susceptibility gene ZNF804A alters expression of genes in-
volved in cell adhesion. Hum Mol Genet. 2012;21:1018‐1024.
51. Girgenti MJ, LoTurco JJ, Maher BJ. ZNF804a regulates expression
of the schizophrenia-­associated genes PRSS16, COMT, PDE4B, and
DRD2. PLoS ONE. 2012;7:e32404.
How to cite this article: Baek JH, Ha K, Kim Y, et al.
Association between the zinc finger protein 804A (ZNF804A)
gene and the risk of schizophrenia and bipolar I disorder across
diagnostic boundaries. Bipolar Disord. 2017;00:1–9.
https://doi.org/10.1111/bdi.12493