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The Effects of Light-to-Moderate Alcohol Consumption on the Cognitive Function of Community Nondemented Male Elderly: A Cohort Study. Behav Neurol 2021; 2021:5681913. [PMID: 33833827 PMCID: PMC8018835 DOI: 10.1155/2021/5681913] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 01/23/2021] [Accepted: 02/23/2021] [Indexed: 11/18/2022] Open
Abstract
Aim To investigate the effects of light-to-moderate drinking on the cognitive function of the elderly in a large elderly community cohort. Although heavy drinking is linked with impaired brain functions, the effects of light-to-moderate drinking on the cognitive function of the elderly are still controversial. Methods A total of 1469 nondemented elderly men from 15 research centers in 8 cities and provinces were included and divided into two groups: drinking (531 subjects) and nondrinking (938 subjects). Cognitive functions were assessed by the Beijing version of the Montreal Cognitive Assessment (MoCA) at baseline and one-year follow-up. Results There was no difference in total cognitive scores between the light-to-moderate drinking and nondrinking groups at baseline and follow-up. Nonalcohol users performed better naming and abstraction function at baseline and better naming function at follow-up. There was no difference in cognitive performance decline and new-onset dementia rates at follow-up. Conclusions Light-to-moderate alcohol consumption had no significant impact on the overall cognitive function and the risk of dementia in elderly men.
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Syaifullah AH, Shiino A, Fujiyoshi A, Kadota A, Kondo K, Ito T, Segawa H, Moniruzzaman M, Waki T, Miyagawa N, Tooyama I, Ueshima H, Miura K, Ueshima H, Miura K. Alcohol drinking and brain morphometry in apparently healthy community-dwelling Japanese men. Alcohol 2021; 90:57-65. [PMID: 33278513 DOI: 10.1016/j.alcohol.2020.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/26/2020] [Accepted: 11/27/2020] [Indexed: 12/21/2022]
Abstract
The clinical implications of alcohol consumption have been extensively examined; however, its effects on brain structures in apparently healthy community-dwellers remain unclear. Therefore, we investigated the relationship between alcohol consumption and brain gray matter volume (GMV) in community-dwelling Japanese men using voxel-based morphometry (VBM). We recruited cognitively intact Japanese men, aged 40-79 years, from a population-based cohort in Shiga, Japan. Brain magnetic resonance imaging was performed, on average, 2 years after demographic and medical information was obtained in 2010-2014. A multivariable linear regression analysis of 639 men was conducted to elucidate the relationship between the amount of alcohol consumed and GMV. VBM statistics were analyzed by threshold-free cluster enhancement with a family-wise error rate of <0.05. The results obtained demonstrated that the amount of alcohol consumed was associated with lower GMV. The VBM analysis showed lower GMV within the parahippocampal, entorhinal, cingulate, insular, temporal, and frontal cortices and cerebellum in very heavy drinkers (≥42 ethanol g/day) than in non-drinkers. Furthermore, alcohol consumption was associated with a higher white matter lesion volume. These results suggest subclinical structural changes similar to alcohol-related neurological diseases.
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Affiliation(s)
- Ali Haidar Syaifullah
- Biomedical MRI Science Center, Shiga University of Medical Science, Shiga, Japan; Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan
| | - Akihiko Shiino
- Biomedical MRI Science Center, Shiga University of Medical Science, Shiga, Japan.
| | - Akira Fujiyoshi
- Department of Hygiene, School of Medicine, Wakayama Medical University, Japan; Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Aya Kadota
- Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan; Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Keiko Kondo
- Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Takahiro Ito
- Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Hiroyoshi Segawa
- Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan
| | - Mohammad Moniruzzaman
- Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan; Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Takashi Waki
- Department of Medical Statistics, Shiga University of Medical Science, Shiga, Japan
| | - Naoko Miyagawa
- Department of Public Health, Shiga University of Medical Science, Shiga, Japan; International Center for Nutrition and Information, National Institute of Biomedical Innovation, Health and Nutrition, Shinjuku-ku, Tokyo, Japan
| | - Ikuo Tooyama
- Molecular Neuroscience Research Center, Shiga University of Medical Science, Shiga, Japan
| | - Hirotsugu Ueshima
- Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan; Department of Public Health, Shiga University of Medical Science, Shiga, Japan
| | - Katsuyuki Miura
- Center for the Epidemiologic Research in Asia (CERA), Shiga University of Medical Science, Shiga, Japan; Department of Public Health, Shiga University of Medical Science, Shiga, Japan
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Moderate alcohol use is associated with decreased brain volume in early middle age in both sexes. Sci Rep 2020; 10:13998. [PMID: 32814788 PMCID: PMC7438498 DOI: 10.1038/s41598-020-70910-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 07/28/2020] [Indexed: 11/08/2022] Open
Abstract
The aim was to examine cross-sectional association between moderate alcohol consumption and total brain volume in a cohort of participants in early middle-age, unconfounded by age-related neuronal change. 353 participants aged 39 to 45 years reported on their alcohol consumption using the AUDIT-C measure. Participants with alcohol abuse were excluded. Brain MRI was analyzed using a fully automated method. Brain volumes were adjusted by intracranial volume expressed as adjusted total brain volume (aTBV). AUDIT-C mean of 3.92 (SD 2.04) indicated moderate consumption. In a linear regression model, alcohol consumption was associated with smaller aTBV (B = - 0.258, p < .001). When sex and current smoking status were added to the model, the association remained significant. Stratified by sex, the association was seen in both males (B = - 0.258, p = 0.003) and females (B = - 0.214, p = 0.011). Adjusted for current smoking, the association remained in males (B = - 0.268, p = 0.003), but not in females. When alcohol consumption increased, total brain volume decreased by 0.2% per one AUDIT-C unit already at 39-45 years of age. Moderate alcohol use is associated with neuronal changes in both males and females suggesting health risks that should not be overlooked.
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Klauss J, Anders QS, Felippe LV, Nitsche MA, Nakamura-Palacios EM. Multiple Sessions of Transcranial Direct Current Stimulation (tDCS) Reduced Craving and Relapses for Alcohol Use: A Randomized Placebo-Controlled Trial in Alcohol Use Disorder. Front Pharmacol 2018; 9:716. [PMID: 30018558 PMCID: PMC6037838 DOI: 10.3389/fphar.2018.00716] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2018] [Accepted: 06/13/2018] [Indexed: 01/17/2023] Open
Abstract
Background: Transcranial direct current stimulation (tDCS), a non-invasive brain stimulation technique, has been studied as an adjunctive therapeutic agent for alcohol dependence. In a previous study, we showed that five consecutive sessions of tDCS applied bilaterally over the dorsolateral prefrontal cortex (dlPFC) reduced relapse to the use of alcohol in alcohol use disorder (AUD) outpatients. However, no changes on craving scores were observed. In the present study, we investigated if an extended number of sessions of the same intervention would reduce craving and relapses for alcohol use in AUD inpatients. Methods: Thus, a randomized, double-blind, sham-controlled, clinical trial with parallel arms was conducted (https://clinicaltrials.gov/ct2/show/NCT02091284). AUD patients from two private and one public clinics for treatment of drug dependence were randomly allocated to two groups: real tDCS (5 × 7 cm2, 2 mA, for 20 min, cathodal over the left dlPFC, and anodal over the right dlPFC) and sham-tDCS. Real or sham-tDCS was applied once a day, every other day, in a total of 10 sessions. Craving was monitored by a 5-item obsessive compulsive drinking scale once a week (one time before, three times during and once after brain stimulation) over about 5 weeks. Results: Craving scores progressively decreased over five measurements in both groups but were significantly reduced only in the real tDCS group after treatment. Corrected Hedges' within-group (initial and final) effect sizes of craving scores were of 0.3 for the sham-tDCS and of 1.1 for the real tDCS group. Effect size was 3-fold larger in the real tDCS group. In addition, the between-group analysis on craving score difference was nearly significant, and the effect size was 0.58, in favor for a larger effect in the real tDCS group when compared to sham-tDCS. Furthermore, in a 3-months follow-up after intervention, 72.2% of sham-tDCS group relapsed to the alcohol use whereas 72.7% of tDCS group were abstinent. Conclusions: Multiple sessions of bilateral prefrontal tDCS were well tolerated with no significant adverse events. Thus, extended repetitive bilateral tDCS over the dlPFC is a promising adjunctive clinical tool that could be used to reduce alcohol craving and relapses and facilitate alcoholism cessation.
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Affiliation(s)
- Jaisa Klauss
- Program of Post-Graduation in Physiological Sciences, Laboratory of Cognitive Sciences and Neuropsychopharmacology, Health Sciences Center, Federal University of Espírito Santo, Vitória, Brazil
| | - Quézia S Anders
- Program of Post-Graduation in Physiological Sciences, Laboratory of Cognitive Sciences and Neuropsychopharmacology, Health Sciences Center, Federal University of Espírito Santo, Vitória, Brazil
| | - Luna V Felippe
- Program of Post-Graduation in Physiological Sciences, Laboratory of Cognitive Sciences and Neuropsychopharmacology, Health Sciences Center, Federal University of Espírito Santo, Vitória, Brazil
| | - Michael A Nitsche
- Leibniz Research Centre for Working Environment and Human Resources, Dortmund, Germany.,Department of Neurology, University Medical Hospital Bergmannsheil, Bochum, Germany
| | - Ester M Nakamura-Palacios
- Program of Post-Graduation in Physiological Sciences, Laboratory of Cognitive Sciences and Neuropsychopharmacology, Health Sciences Center, Federal University of Espírito Santo, Vitória, Brazil
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Topiwala A, Allan CL, Valkanova V, Zsoldos E, Filippini N, Sexton C, Mahmood A, Fooks P, Singh-Manoux A, Mackay CE, Kivimäki M, Ebmeier KP. Moderate alcohol consumption as risk factor for adverse brain outcomes and cognitive decline: longitudinal cohort study. BMJ 2017; 357:j2353. [PMID: 28588063 PMCID: PMC5460586 DOI: 10.1136/bmj.j2353] [Citation(s) in RCA: 225] [Impact Index Per Article: 32.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives To investigate whether moderate alcohol consumption has a favourable or adverse association or no association with brain structure and function.Design Observational cohort study with weekly alcohol intake and cognitive performance measured repeatedly over 30 years (1985-2015). Multimodal magnetic resonance imaging (MRI) was performed at study endpoint (2012-15).Setting Community dwelling adults enrolled in the Whitehall II cohort based in the UK (the Whitehall II imaging substudy).Participants 550 men and women with mean age 43.0 (SD 5.4) at study baseline, none were "alcohol dependent" according to the CAGE screening questionnaire, and all safe to undergo MRI of the brain at follow-up. Twenty three were excluded because of incomplete or poor quality imaging data or gross structural abnormality (such as a brain cyst) or incomplete alcohol use, sociodemographic, health, or cognitive data.Main outcome measures Structural brain measures included hippocampal atrophy, grey matter density, and white matter microstructure. Functional measures included cognitive decline over the study and cross sectional cognitive performance at the time of scanning.Results Higher alcohol consumption over the 30 year follow-up was associated with increased odds of hippocampal atrophy in a dose dependent fashion. While those consuming over 30 units a week were at the highest risk compared with abstainers (odds ratio 5.8, 95% confidence interval 1.8 to 18.6; P≤0.001), even those drinking moderately (14-21 units/week) had three times the odds of right sided hippocampal atrophy (3.4, 1.4 to 8.1; P=0.007). There was no protective effect of light drinking (1-<7 units/week) over abstinence. Higher alcohol use was also associated with differences in corpus callosum microstructure and faster decline in lexical fluency. No association was found with cross sectional cognitive performance or longitudinal changes in semantic fluency or word recall.Conclusions Alcohol consumption, even at moderate levels, is associated with adverse brain outcomes including hippocampal atrophy. These results support the recent reduction in alcohol guidance in the UK and question the current limits recommended in the US.
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Affiliation(s)
- Anya Topiwala
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Charlotte L Allan
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Vyara Valkanova
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Enikő Zsoldos
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Nicola Filippini
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Claire Sexton
- FMRIB Centre, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, OX3 9DU, UK
| | - Abda Mahmood
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Peggy Fooks
- University of Oxford, Warneford Hospital, Oxford, OX3 9DU, UK
| | - Archana Singh-Manoux
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Clare E Mackay
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
| | - Mika Kivimäki
- Department of Epidemiology and Public Health, University College London, London, WC1E 6BT, UK
| | - Klaus P Ebmeier
- Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK
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Lange EH, Nerland S, Jørgensen KN, Mørch-Johnsen L, Nesvåg R, Hartberg CB, Haukvik UK, Osnes K, Melle I, Andreassen OA, Agartz I. Alcohol use is associated with thinner cerebral cortex and larger ventricles in schizophrenia, bipolar disorder and healthy controls. Psychol Med 2017; 47:655-668. [PMID: 27830632 DOI: 10.1017/s0033291716002920] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Excessive alcohol use is associated with brain damage but less is known about brain effects from moderate alcohol use. Previous findings indicate that patients with severe mental illness, particularly schizophrenia, are vulnerable to alcohol-related brain damage. We investigated the association between levels of alcohol consumption and cortical and subcortical brain structures in schizophrenia and bipolar disorder patients and healthy controls, and investigated for group differences for this association. METHOD 1.5 T structural magnetic resonance images were acquired of 609 alcohol-using participants (165 schizophrenia patients, 172 bipolar disorder patients, 272 healthy controls), mean (s.d.) age 34.2 (9.9) years, 52% men. Past year alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption part (AUDIT-C). General linear models were used to investigate associations between AUDIT-C score and cortical thickness, surface area, and total brain and subcortical volumes. RESULTS Increasing AUDIT-C score was linearly associated with thinner cortex in medial and dorsolateral frontal and parieto-occipital regions, and with larger left lateral ventricle volume. There was no significant interaction between AUDIT-C score and diagnostic group. The findings remained significant after controlling for substance use disorders, antipsychotic medication and illness severity. CONCLUSION The results show a dose-dependent relationship between alcohol use and thinner cortex and ventricular expansion. The findings are present also at lower levels of alcohol consumption and do not differ between schizophrenia or bipolar disorder patients compared to healthy controls. Our results do not support previous findings of increased vulnerability for alcohol-related brain damage in severe mental illness.
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Affiliation(s)
- E H Lange
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - S Nerland
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - K N Jørgensen
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - L Mørch-Johnsen
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - R Nesvåg
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - C B Hartberg
- NORMENT and K. G. Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, University of Oslo,Oslo,Norway
| | - U K Haukvik
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - K Osnes
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
| | - I Melle
- NORMENT and K. G. Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, University of Oslo,Oslo,Norway
| | - O A Andreassen
- NORMENT and K. G. Jebsen Centre for Psychosis Research, Institute of Clinical Medicine, University of Oslo,Oslo,Norway
| | - I Agartz
- Department of Psychiatric Research,Diakonhjemmet Hospital,Oslo,Norway
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Bullock K, Cservenka A, Ray LA. Severity of alcohol dependence is negatively related to hypothalamic and prefrontal cortical gray matter density in heavy drinking smokers. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 43:281-290. [PMID: 27996310 DOI: 10.1080/00952990.2016.1257632] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND While research has examined brain structure in individuals who use alcohol or nicotine, heavy drinking smokers comprise a unique subpopulation of substance users for whom less is known about the relationship between alcohol or nicotine use and structural brain abnormalities. OBJECTIVES The present study examined gray matter morphometry in a sample of 39 heavy drinking smokers (24 males, 15 females) in relation to alcohol and nicotine dependence and quantity of use. METHODS Traditional voxel-based morphometry techniques were employed for preprocessing of imaging data. One multiple regression analysis for alcohol and nicotine dependence severity and another for alcohol and nicotine quantity of use were conducted, while controlling for age, gender, and total intracranial volume (ICV). RESULTS Alcohol dependence severity was significantly negatively associated with gray matter density in the hypothalamus (p < 0.001, uncorrected) and the right superior frontal gyrus (p < 0.001, uncorrected), while controlling for nicotine dependence severity, age, gender, and ICV. There were no significant relationships observed with respect to nicotine dependence severity, the quantity of alcohol use, or the quantity of nicotine use variables and gray matter density. CONCLUSIONS These findings suggest that within heavy drinking smokers, alcohol dependence severity is significantly related to alterations in brain structure, while this effect is not seen for the quantity of alcohol or nicotine use, or severity of nicotine dependence. The current findings help clarify the contribution of alcohol and nicotine effects on brain structure, which could aid in understanding their neurocognitive consequences in heavy drinking smokers.
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Affiliation(s)
- Kyle Bullock
- a Department of Psychology , University of California , Los Angeles , CA , USA
| | - Anita Cservenka
- b School of Psychological Science , Oregon State University , Corvallis , OR , USA
| | - Lara A Ray
- a Department of Psychology , University of California , Los Angeles , CA , USA.,c Department of Psychiatry and Biobehavioral Sciences , University of California , Los Angeles , CA , USA.,d Brain Research Institute , University of California , Los Angeles , CA , USA
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Piras AP, Preti A, Moro MF, Giua A, Sini G, Piras M, Pintus M, Pintus E, Manca A, Cannas G, Cossu G, Angermeyer MC, Carta MG. Does calling alcoholism an illness make a difference? The public image of alcoholism in Italy. Drug Alcohol Depend 2016; 166:39-44. [PMID: 27373185 DOI: 10.1016/j.drugalcdep.2016.06.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 06/15/2016] [Accepted: 06/17/2016] [Indexed: 10/21/2022]
Abstract
AIMS Using data from a population survey in two communities in the region of Sardinia, Italy, we examined the association between illness definition and attribution of personal characteristics to people with alcoholism. METHODS Quota samples, stratified by gender and age, were drawn from the general population (males: 48%; mean age 48±18; range: 15-90). A fully-structured interview was conducted face-to-face with 404 respondents. The assessment of the public view of 'alcoholics' was measured by their reactions to stimulus words rated on bipolar scales, and defined with adjectives with opposite meanings at each end. RESULTS 322 participants (80%) rated the 'alcoholic' as 'ill'. The definition of the 'alcoholic' as being ill showed a statistically higher odd of stigma across all the dimensions of personal attributes. CONCLUSIONS The expectation that people adopting the illness model would tend to blame less those afflicted for their condition and, consequently, stigmatize them less, was not confirmed.
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Affiliation(s)
- Anna Paola Piras
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy; Dipartimento di Sanità Pubblica, Medicina Clinica e Molecolare, Università di Cagliari, Cagliari, Italy
| | - Antonio Preti
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy.
| | - Maria Francesca Moro
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy
| | - Alice Giua
- Corso di Laurea in Tecnico della Riabilitazione Psichiatrica, Università di Cagliari, Cagliari, Italy
| | - Giulia Sini
- Corso di Laurea in Tecnico della Riabilitazione Psichiatrica, Università di Cagliari, Cagliari, Italy
| | - Martina Piras
- Corso di Laurea in Tecnico della Riabilitazione Psichiatrica, Università di Cagliari, Cagliari, Italy
| | - Mirra Pintus
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy
| | - Elisa Pintus
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy
| | - Annaraffaela Manca
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy
| | - Glenda Cannas
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy
| | - Giulia Cossu
- Dipartimento di Sanità Pubblica, Medicina Clinica e Molecolare, Università di Cagliari, Cagliari, Italy
| | - Matthias Claus Angermeyer
- Dipartimento di Sanità Pubblica, Medicina Clinica e Molecolare, Università di Cagliari, Cagliari, Italy
| | - Mauro Giovanni Carta
- Centro di Psichiatria e di Consultazione Psicosomatica Azienda Ospedaliero Universitaria S. Giovanni di Dio, Cagliari, Italy; Dipartimento di Sanità Pubblica, Medicina Clinica e Molecolare, Università di Cagliari, Cagliari, Italy; Corso di Laurea in Tecnico della Riabilitazione Psichiatrica, Università di Cagliari, Cagliari, Italy
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