Safety of electroconvulsive therapy (ECT) in pregnancy: a systematic review of case reports and case series

Pregnancy and the immediate postpartum period are considered at high risk for women who have already received a previous psychiatric diagnosis and might represent a stressful event favoring the onset of new psychiatric disorders. The electroconvulsive therapy (ECT) is effective for the treatment of severe, treatment-resistant mental disorders, and it could represent a therapeutic choice for psychiatric conditions during pregnancy. The purpose of this systematic review is to evaluate the safety of ECT during pregnancy and to update the state of the art of its use. An extensive literature search on PubMed, APA PsycInfo, and Scopus databases for relevant articles published from inception to September 2023 has been performed. A final number of 45 articles (34 case reports and 11 case series, for a total of 130 pregnant women) were included in the present review. The limited evidence confirmed that ECT is effective in determining a partial remission of symptoms in women suffering from severe mental disorders, especially in the presence of suicidal ideation or psychosis, during all pregnancy epochs. However, ECT is not free from side effects, although the majority of possible complications were of low- or moderate-grade and not life-threatening for the women. Exposure to pharmacological treatment before or during the ECT or to the anesthetic during ECT might have contributed to the onset of these complications. ECT techniques evolved over years, increasing the degree of its safety, and according to our review it appears to be relatively safe and effective during pregnancy in the majority of cases.

Bidirectional Relationship between HIV/HBV Infection and Comorbid Depression and/or Anxiety: A Systematic Review on Shared Biological Mechanisms

BACKGROUND

Mental disorders that are comorbid with chronic infectious diseases may worsen clinical outcomes and patients' quality of life. We hypothesized that depression and/or anxiety syndromes or symptoms comorbid with human immunodeficiency virus (HIV) or hepatitis B virus (HBV) infection might stem from shared biological mechanisms.

METHODS

We conducted a systematic review applying the PRISMA statement by searching into the PubMed, APA PsycInfo, and Scopus databases. We examined the literature on HIV/HBV infection comorbid with depression and/or anxiety in adults ≥18 years.

RESULTS

Thirty-one studies on HIV and three on HBV were analyzed. The Tat protein contributed to HIV-associated mood disorders due to the protein's ability to cause neurodegeneration and induce hypothalamic-pituitary-adrenal (HPA) axis dysregulation in response to natural stressors. The decreased brain-derived neurotrophic factor (BDNF) levels also emerged as a mechanism involved in HIV neuropathogenesis and the associated mood symptoms. Neuroinflammation was implicated in depression and/or anxiety onset in patients with HIV/HBV infections. Microglial activation and release of cytokines, in particular, appeared as potential pathogenetic mechanisms. Furthermore, an altered balance between quinolinic acid and kynurenic acid production emerged in HIV patients with comorbid depression, indicating a glutamatergic dysfunction. Inflammatory cytokine production and the downregulation of cellular immune responses contributed to persisting inflammation, delayed healing, and functional decline in patients with chronic hepatitis B (CHB) infection. A shift in type 1-type 2 cytokine balance might be implicated in HBV-related immune pathogenesis, and depression and anxiety might be considered immunomodulatory factors. Cytokines also caused HPA axis hyperactivity, frequently observed in HIV/HBV patients with comorbid depression/anxiety.

CONCLUSIONS

The present systematic review showed, for the first time, that HIV/HBV and depression and/or anxiety might have several biological mechanisms as common denominators. The longitudinal course of the highlighted biological mechanisms should be explored to establish the causative interrelationship among the involved mechanisms. In addition, future research should investigate the possibility that a patient's clinical outcome might improve using pharmacological treatments acting on the biological mechanisms we described as common denominators of chronic inflammatory infective diseases and depression/anxiety.

Acute stress symptoms in general population during the first wave of COVID lockdown in Italy: Results from the COMET trial

BACKGROUND

The coronavirus disease of 2019 (COVID-19) pandemic is an unprecedented traumatic event that has severely impacted social, economic, and health well-being worldwide. The COvid Mental hEalth Trial was specifically designed to evaluate the impact of the COVID-19 pandemic and its containment measures on the mental health of the Italian general population in terms of COVID-19-related acute stress disorder (ASD) symptoms.

METHODS

The present cross-sectional study is based on an online survey carried out in the period March-May 2020. Italian general adult population was invited to compile an anonymous survey, which included the severity of acute stress symptoms scale/National Stressful Events Survey Short Scale to investigate the occurrence and severity of ASD symptoms.

RESULTS

The final sample consisted of 20,720 participants. During the lockdown, subjects with pre-existing mental health problems reported a statistically significant higher risk of acute post-traumatic symptoms compared to the general population (B: 2.57; 95% CI:2.04-3.09; p < .0001) and health care professionals (B: .37; 95% CI: .02-0.72; p < .05). According to multivariate regression models, the levels of acute post-traumatic symptoms (p < .0001) were higher in younger and female respondents. Social isolation and sleep disorder/insomnia represented positive predictors of acute stress (B = 3.32, 95% CI = 3.08-3.57).

CONCLUSIONS

Concerns about the risk of infection as well as social isolation caused a higher incidence of acute post-traumatic stress symptoms that may predict the subsequent development of post-traumatic stress disorder symptoms in the long term.

A Systematic Review on the Effectiveness of Antipsychotic Drugs on the Quality of Life of Patients with Schizophrenia

Pharmacological antipsychotic drug interventions represent the cornerstone of the management of patients with schizophrenia and other psychotic spectrum disorders. The choice of the "best" treatment should be made on the basis of several clinical domains. However, despite available treatments, the quality of life reported by patients with schizophrenia taking antipsychotics is still very poor, and this outcome is rarely taken into account in trials assessing the efficacy and effectiveness of antipsychotic treatments. Therefore, we performed a systematic review in order to assess the impact of antipsychotic treatment on patients' quality of life. In particular, we aimed to identify any differences in the improvement in quality of life according to the (a) type of formulation of antipsychotic drugs (i.e., oral vs. depot vs. long-acting injectable); (b) type of the drug (first vs. second vs. third generation); and (c) patients' clinical characteristics. One hundred and eleven papers were included in the review. The main findings were as follows: (1) quality of life is usually considered a secondary outcome in trials on the efficacy and effectiveness of drugs; (2) second-generation antipsychotics have a more positive effect on quality of life; and (3) long-acting injectable antipsychotics are associated with a more stable improvement in quality of life and with a good safety and tolerability profile. Our systematic review confirms that quality of life represents a central element for selecting the appropriate treatment for people with schizophrenia. In particular, the availability of new treatments with a better tolerability profile, a proven effectiveness on patients' cognitive and social functioning, and with a more stable blood concentration might represent the appropriate strategy for improving the quality of life of people with schizophrenia.

Organizational and Individual Interventions for Managing Work-Related Stress in Healthcare Professionals: A Systematic Review

The workplace represents a relevant source of stress for workers, being a risk factor for many mental disorders and psychological difficulties, including burn-out syndrome. Healthcare workers and other help-professions are particularly susceptible to work-related stress. The present systematic review aims to (1) identify available interventions for managing workplace-related stress symptoms; (2) assess their efficacy; and (3) discuss the current limitations of available interventions. A systematic review has been conducted, searching on PubMed, APA PsycInfo, and Scopus databases. Eighteen papers have been identified, which included different interventions for the management of work-related stress in healthcare professionals. These approaches can be grouped as follows: (1) interventions focusing on the individual level using cognitive-behavioral therapy (CBT) approaches; (2) interventions focusing on the individual level using relaxation techniques; and (3) interventions focusing on the organizational level. As regards interventions targeting the individual level using CBT approaches, mindfulness-based interventions were effective in reducing levels of burn-out, stress, and anxiety and in improving quality of life. As regards intervention using relaxation techniques, including art therapy, Emotional Freedom Techniques (ECT) and brief resilience retreats had a positive effect on the levels of anxiety, stress, and burnout. As regards interventions at the organizational level, we found no evidence for supporting its effectiveness in reducing the levels of burnout. Furthermore, available studies are heterogeneous in terms of assessment tools, target populations, and type of interventions, which limits the generalizability of findings.

Duration of Untreated Illness in Patients with Obsessive-Compulsive Disorder and Its Impact on Long-Term Outcome: A Systematic Review

Background: Duration of untreated illness (DUI)-defined as the time period between the onset of a mental disorder and its first adequate treatment-should influence patients' long-term prognosis and outcome. In patients with obsessive-compulsive disorder (OCD), DUI lasts on average from 87.5 up to 94.5 months, being significantly longer compared with data available from patients affected by other severe mental disorders, such as schizophrenia and bipolar disorder. We carried out a systematic review in order to assess the impact of DUI on long-term outcomes in OCD patients. Methods: A systemic review has been implemented, searching from inception to April 2023; only papers written in English were included. Results: Seventy-one articles were initially identified; only eight papers were included in the review. The DUI ranged from 7.0 ± 8.5 to 20.9 ± 11.2 years. Patients reporting a longer DUI have a poor long-term outcome in terms of lower level of treatment response and greater symptom severity. Conclusions: The present review confirms that longer DUI has a negative impact on the long-term outcome of patients with OCD. It should be useful to promote the dissemination of early interventions with a specific focus on OCD symptoms.

Second-Generation Antipsychotics’ Effectiveness and Tolerability: A Review of Real-World Studies in Patients with Schizophrenia and Related Disorders

Despite methodological limitations, real-world studies might support clinicians by broadening the knowledge of antipsychotics’ (APs) effectiveness and tolerability in different clinical scenarios and complement clinical trials. We conducted an extensive literature search in the PubMed database to evaluate the effectiveness and tolerability profiles of second-generation antipsychotics (SGAs) from real-world studies to aid clinicians and researchers in selecting the proper treatment for patients with schizophrenia and related disorders. The present review evidenced that SGAs demonstrated superior effectiveness over first-generation antipsychotics (FGAs) in relapse-free survival and psychiatric hospitalization rate and for treating negative symptoms. Persistence and adherence to therapy were higher in SGAs than FGAs. Most studies concluded that switching to long-acting injectables (LAIs) was significantly associated with a lower treatment failure rate than monotherapy with oral SGAs. Considerable improvements in general functionality, subjective well-being, and total score on global satisfaction tests, besides improved personal and social performance, were reported in some studies on patients treated with LAI SGAs. Clozapine was also associated with the lowest rates of treatment failure and greater effectiveness over the other SGAs, although with more severe side effects. Effectiveness on primary negative symptoms and cognitive deficits was rarely measured in these studies. Based on the data analyzed in the present review, new treatments are needed with better tolerability and improved effectiveness for negative, affective, and cognitive symptoms.

Does Vitamin D matter? The role of calcium homeostasis imbalance in clinical severity of psychiatric patients

Introduction

Vitamin D modulates the biosynthesis of neurotransmitters and neurotrophic factors and it is involved in the modulation of inflammatory responses, with a potential impact on clinical status of patients with severe mental disorders. Moreover, available evidences report that decreased blood levels of Vitamin D are associated to a worse course of psychotic and affective disorders.

Objectives

We assessed calcium homeostasis imbalance in a sample of inpatients and outpatients, referring to the Department of Psychiatry of University of Campania “Luigi Vanvitelli” in order to explore levels of Calcium, PTH and Vitamin D and their influence in clinical severity among this different subgroups.

Methods

All patients were administered The Brief Psychiatric Rating Scale (BPRS) to assess different domains of psychopathology. Vitamin D, Calcium and PTH levels were assessed in all patients. An-ad hoc schedule was administered for socio-demographic and clinical characteristics.

Results

The total sample consisted of 152 patients (75 males and 77 females with 47.3 ± 14.4 age at admission, 74 inpatients and 78 outpatients). Patients with lower level of Vitamin D are more likely to present higher number of relapses (p<0.05) and to be inpatients (<0.01). Finally, serum levels of Vitamin D were negatively correlated with all the BPRS subscales (p < 0.01).

Conclusions

Lower levels of Vitamin D correlate with a worse clinical outcome of patients with different psychiatric diagnosis. Our results highlight the importance to routinely assess PTH, Vit D and calcium levels, especially in inpatients. Moreover, Vitamin D may represent a valid add-on treatment for these patients.

Disclosure

No significant relationships.

A systematic review on shared biological mechanisms of depression and anxiety in comorbidity with psoriasis, atopic dermatitis, and hidradenitis suppurativa

BACKGROUND

Mental disorders in comorbidity with chronic skin diseases may worsen disease outcome and patients' quality of life. We hypothesized the comorbidity of depression, anxiety syndromes, or symptoms as attributable to biological mechanisms that the combined diseases share.

METHODS

We conducted a systematic review based on the Preferred Reporting Items for Systematic Review and Meta-Analysis statement searching into PubMed, PsycInfo, and Scopus databases. We examined the literature regarding the comorbidity of psoriasis (Ps), atopic dermatitis (AD), or hidradenitis suppurativa with depression and/or anxiety in adults ≥18 years and the hypothetical shared underlying biological mechanisms.

RESULTS

Sixteen studies were analyzed, mostly regarding Ps and AD. Brain-derived neurotrophic factor/tropomyosin receptor kinase B signaling and nuclear factor kappa-light-chain-enhancer of activated B cells/p38 mitogen-activated protein kinase pathways arose as shared mechanisms in Ps animal models with depression- and/or anxiety-like behaviors. Activated microglia and neuroinflammatory responses emerged in AD depressive models. As to genetic studies, atopic-dermatitis patients with comorbid anxiety traits carried the short variant of serotonin transporter and a polymorphism of the human translocator protein gene. A GA genotype of catechol-O-methyltransferase gene was instead associated with Ps. Reduced natural killer cell activity, IL-4, serotonin serum levels, and increased plasma cortisol and IgE levels were hypothesized in comorbid depressive AD patients. In Ps patients with comorbid depression, high serum concentrations of IL-6 and IL-18, as well as IL-17A, were presumed to act as shared inflammatory mechanisms.

CONCLUSIONS

Further studies should investigate mental disorders and chronic skin diseases concurrently across patients' life course and identify their temporal relation and biological correlates. Future research should also identify biological characteristics of individuals at high risk of the comorbid disorders and associated complications.