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Iannuzzo F, Garzon S, Lazzari C, Porcari I, Bosco M, Etrusco A, Laganà AS, Uccella S, Chiantera V, Celebre L, Mento C, Muscatello MRA, Bruno A. Sleep disorders and hyperarousal among patients with endometriosis: A case-control survey study. Eur J Obstet Gynecol Reprod Biol 2024; 300:287-295. [PMID: 39053089 DOI: 10.1016/j.ejogrb.2024.07.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 07/09/2024] [Accepted: 07/13/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Endometriosis has been associated with sleep disorders, and hyperarousal appears to be involved in their pathogenesis; however, the presence of hyperarousal in the endometriosis population was never investigated. METHODS We conducted a case-control survey study by sending a questionnaire to all endometriosis patients followed up at our Centers. Controls were recruited among the general population. The questionnaire included demographic information, symptoms and history of endometriosis, the Hyperarousal Scale (H-Scale), the Pittsburgh Sleep Quality Index (PSQI), and the Insomnia Severity Index (ISI). RESULTS A total of 847 women completed the questionnaires: 430 (50.8 %) had endometriosis, and 417 (49.2 %) were controls. Endometriosis was associated with higher H-scale score (OR 2.9, 95 % CI 2.4-3.8, p = 0.000), higher PSQI score (OR 4.3, 95 % CI 3.2-5.7, p = 0.000), and higher ISI score (OR 4.6, 95 % CI 3.5-6.1, p = 0.000) in multivariable ordinal logistic regressions analysis. With path analysis, hyperarousal (H-Scale) reported a partial mediating role in the association between endometriosis and sleep disorders. The mediation effect represented 22.3-27.8 % of the entire association between endometriosis and sleep disturbances. CONCLUSION Endometriosis patients complaining sleep disorders may benefit by investigating the presence of hyperarousal given cognitive behavioral therapy was reported effective in improving hyperarousal and associated sleep disorders.
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Affiliation(s)
- Fiammetta Iannuzzo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, Contesse, Messina 98125, Italy
| | - Simone Garzon
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Cecilia Lazzari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Irene Porcari
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Mariachiara Bosco
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Andrea Etrusco
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, University of Palermo, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Antonio Simone Laganà
- Unit of Obstetrics and Gynecology, "Paolo Giaccone" Hospital, University of Palermo, Palermo, Italy; Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Stefano Uccella
- Unit of Obstetrics and Gynecology, Department of Surgery, Dentistry, Pediatrics, and Gynecology, AOUI Verona, University of Verona, Verona, Italy
| | - Vito Chiantera
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy; Unit of Gynecologic Oncology, National Cancer Institute - IRCCS - Fondazione "G. Pascale", Naples, Italy
| | - Laura Celebre
- Department of Mental Health and Addictions, ASST Papa Giovanni XXIII, Piazza OMS 1, Bergamo 24127, Italy
| | - Carmela Mento
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, Contesse, Messina 98125, Italy
| | - Maria Rosaria Anna Muscatello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, Contesse, Messina 98125, Italy
| | - Antonio Bruno
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Via Consolare Valeria 1, Contesse, Messina 98125, Italy.
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La Verde M, Luciano M, Fordellone M, Brandi C, Carbone M, Di Vincenzo M, Lettieri D, Palma M, Marrapodi MM, Scalzone G, Torella M. Is there a correlation between prepartum anaemia and an increased likelihood of developing postpartum depression? A prospective observational study. Arch Gynecol Obstet 2024; 310:1099-1108. [PMID: 38345767 PMCID: PMC11258048 DOI: 10.1007/s00404-023-07344-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/12/2023] [Indexed: 07/19/2024]
Abstract
PURPOSE Postpartum depression (PPD) represents a significant challenge to maternal and child health. Early screening for PPD is essential to ensure appropriate treatment and support. The present study aimed to assess whether maternal prepartum anaemia influences the likelihood of developing PPD within 3 days after delivery. METHODS In collaboration with the Department of Psychiatry, a prospective observational study was carried out at the Gynaecology and Obstetrics Department of the University of Campania "Luigi Vanvitelli" in Naples. A total of 211 full-term pregnant women were enrolled, and their predelivery haemoglobin value was recorded. Women with gestational diabetes, hypertension, pre-eclampsia, intrauterine growth restriction, intellectual disability, or pre-existing diagnosis of psychotic spectrum disorder were excluded. Participants provided written informed consent to fill out the Edinburgh Postnatal Depression Scale (EPDS) 3 days after delivery. EPDS cut-off score of ≥ 10 was used to identify women at risk of developing PPD. Statistical analysis was performed using Student's t test, the Wilcoxon Rank Sum test, and linear regression. RESULTS The participants were categorized into 2 groups based on EPDS scores: EPDS < 10 (176 patients) or EPDS ≥ 10 (35 patients). The two groups showed homogeneity in terms of socio-demographic and clinical characteristics. The mean haemoglobin values of anaemic pregnant women in the EPDS ≤ 10 group (11.78 ± 1.39 g/dl) and the EPDS > 10 group (11.62 ± 1.27 g/dl) were not significantly different (p = 0.52). There was no significant correlation between the predelivery haemoglobin value and the EPDS postpartum score of < 10 or ≥ 10. The Wilcoxon Rank Sum test and the estimated coefficients of the linear regression model did not show any statistical relationship between continuous and binary haemoglobin values. CONCLUSIONS Our study found that maternal prepartum anaemia did not negatively impact the likelihood of developing postpartum depressive symptoms, in the first 3 days after delivery.
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Affiliation(s)
- Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Mario Luciano
- Department of Psychiatry, University of Campania, "L. Vanvitelli", Naples, Italy
| | - Mario Fordellone
- Medical Statistics Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Carlotta Brandi
- Department of Psychiatry, University of Campania, "L. Vanvitelli", Naples, Italy
| | - Marco Carbone
- Department of Psychiatry, University of Campania, "L. Vanvitelli", Naples, Italy
| | - Matteo Di Vincenzo
- Department of Psychiatry, University of Campania, "L. Vanvitelli", Naples, Italy
| | - Davide Lettieri
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marica Palma
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Maddalena Marrapodi
- Department of Woman, Child and General and Specialized Surgery, Pediatric Unit, University of Campania Luigi Vanvitelli, Naples, Italy.
| | - Gaetano Scalzone
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco Torella
- Department of Woman, Child and General and Specialized Surgery, Obstetrics and Gynecology Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
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Dwyer DB, Buciuman MO, Ruef A, Kambeitz J, Sen Dong M, Stinson C, Kambeitz-Ilankovic L, Degenhardt F, Sanfelici R, Antonucci LA, Lalousis PA, Wenzel J, Urquijo-Castro MF, Popovic D, Oeztuerk OF, Haas SS, Weiske J, Hauke D, Neufang S, Schmidt-Kraepelin C, Ruhrmann S, Penzel N, Lichtenstein T, Rosen M, Chisholm K, Riecher-Rössler A, Egloff L, Schmidt A, Andreou C, Hietala J, Schirmer T, Romer G, Michel C, Rössler W, Maj C, Borisov O, Krawitz PM, Falkai P, Pantelis C, Lencer R, Bertolino A, Borgwardt S, Noethen M, Brambilla P, Schultze-Lutter F, Meisenzahl E, Wood SJ, Davatzikos C, Upthegrove R, Salokangas RKR, Koutsouleris N. Clinical, Brain, and Multilevel Clustering in Early Psychosis and Affective Stages. JAMA Psychiatry 2022; 79:677-689. [PMID: 35583903 PMCID: PMC9118078 DOI: 10.1001/jamapsychiatry.2022.1163] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 03/23/2022] [Indexed: 12/13/2022]
Abstract
Importance Approaches are needed to stratify individuals in early psychosis stages beyond positive symptom severity to investigate specificity related to affective and normative variation and to validate solutions with premorbid, longitudinal, and genetic risk measures. Objective To use machine learning techniques to cluster, compare, and combine subgroup solutions using clinical and brain structural imaging data from early psychosis and depression stages. Design, Setting, and Participants A multisite, naturalistic, longitudinal cohort study (10 sites in 5 European countries; including major follow-up intervals at 9 and 18 months) with a referred patient sample of those with clinical high risk for psychosis (CHR-P), recent-onset psychosis (ROP), recent-onset depression (ROD), and healthy controls were recruited between February 1, 2014, to July 1, 2019. Data were analyzed between January 2020 and January 2022. Main Outcomes and Measures A nonnegative matrix factorization technique separately decomposed clinical (287 variables) and parcellated brain structural volume (204 gray, white, and cerebrospinal fluid regions) data across CHR-P, ROP, ROD, and healthy controls study groups. Stability criteria determined cluster number using nested cross-validation. Validation targets were compared across subgroup solutions (premorbid, longitudinal, and schizophrenia polygenic risk scores). Multiclass supervised machine learning produced a transferable solution to the validation sample. Results There were a total of 749 individuals in the discovery group and 610 individuals in the validation group. Individuals included those with CHR-P (n = 287), ROP (n = 323), ROD (n = 285), and healthy controls (n = 464), The mean (SD) age was 25.1 (5.9) years, and 702 (51.7%) were female. A clinical 4-dimensional solution separated individuals based on positive symptoms, negative symptoms, depression, and functioning, demonstrating associations with all validation targets. Brain clustering revealed a subgroup with distributed brain volume reductions associated with negative symptoms, reduced performance IQ, and increased schizophrenia polygenic risk scores. Multilevel results distinguished between normative and illness-related brain differences. Subgroup results were largely validated in the external sample. Conclusions and Relevance The results of this longitudinal cohort study provide stratifications beyond the expression of positive symptoms that cut across illness stages and diagnoses. Clinical results suggest the importance of negative symptoms, depression, and functioning. Brain results suggest substantial overlap across illness stages and normative variation, which may highlight a vulnerability signature independent from specific presentations. Premorbid, longitudinal, and genetic risk validation suggested clinical importance of the subgroups to preventive treatments.
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Affiliation(s)
- Dominic B. Dwyer
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Madalina-Octavia Buciuman
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- International Max-Planck Research School for Translational Psychiatry, Munich, Germany
| | - Anne Ruef
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Joseph Kambeitz
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Mark Sen Dong
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Caedyn Stinson
- Max-Planck School of Cognition, Leipzig, Germany
- Center for Adaptive Rationality, Max Planck Institute for Human Development, Berlin, Germany
| | - Lana Kambeitz-Ilankovic
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Franziska Degenhardt
- Institute of Human Genetics, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Rachele Sanfelici
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- Max-Planck Institute of Psychiatry, Munich, Germany
| | - Linda A. Antonucci
- Department of Education, Psychology, Communication, University of Bari Aldo Moro, Bari, Italy
| | - Paris Alexandros Lalousis
- Institute for Mental Health and Centre for Brain Health, University of Birmingham, Birmingham, United Kingdom
| | - Julian Wenzel
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | | | - David Popovic
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- International Max-Planck Research School for Translational Psychiatry, Munich, Germany
| | - Oemer Faruk Oeztuerk
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- International Max-Planck Research School for Translational Psychiatry, Munich, Germany
| | - Shalaila S. Haas
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Johanna Weiske
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
| | - Daniel Hauke
- Department of Psychiatry (Psychiatric University Hospital, UPK), University of Basel, Basel, Switzerland
- Early Intervention Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
- Department of Mathematics and Computer Science, University of Basel, Basel, Switzerland
| | - Susanne Neufang
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | | | - Stephan Ruhrmann
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Nora Penzel
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Theresa Lichtenstein
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Marlene Rosen
- Department of Psychiatry and Psychotherapy, Faculty of Medicine and University Hospital, University of Cologne, Cologne, Germany
| | - Katharine Chisholm
- Institute for Mental Health and Centre for Brain Health, University of Birmingham, Birmingham, United Kingdom
- Department of Psychology, Aston University, Birmingham, United Kingdom
| | | | - Laura Egloff
- Department of Psychiatry (Psychiatric University Hospital, UPK), University of Basel, Basel, Switzerland
| | - André Schmidt
- Department of Psychiatry (Psychiatric University Hospital, UPK), University of Basel, Basel, Switzerland
| | - Christina Andreou
- Department of Psychiatry (Psychiatric University Hospital, UPK), University of Basel, Basel, Switzerland
| | - Jarmo Hietala
- Department of Psychiatry, University of Turku, Turku, Finland
| | - Timo Schirmer
- GE Healthcare GmbH (previously GE Global Research GmbH), Munich, Germany
| | - Georg Romer
- Department of Child and Adolescent Psychiatry, University of Münster, Münster, Germany
| | - Chantal Michel
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - Wulf Rössler
- Department of Psychiatry, Psychotherapy and Psychosomatics, University Hospital of Psychiatry Zurich, Zurich, Switzerland
| | - Carlo Maj
- Institute of Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
| | - Oleg Borisov
- Institute of Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
| | - Peter M. Krawitz
- Institute of Genomic Statistics and Bioinformatics, University of Bonn, Bonn, Germany
| | - Peter Falkai
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- Max-Planck Institute of Psychiatry, Munich, Germany
| | - Christos Pantelis
- Melbourne Neuropsychiatry Centre, University of Melbourne & Melbourne Health, Melbourne, Victoria, Australia
| | - Rebekka Lencer
- Department of Psychiatry and Psychotherapy, University of Münster, Münster, Germany
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Alessandro Bertolino
- Department of Basic Medical Science, Neuroscience and Sense Organs, University of Bari Aldo Moro, Bari, Italy
| | - Stefan Borgwardt
- Department of Psychiatry (Psychiatric University Hospital, UPK), University of Basel, Basel, Switzerland
- Department of Psychiatry and Psychotherapy, University of Lübeck, Lübeck, Germany
| | - Markus Noethen
- Institute of Human Genetics, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn, Germany
| | - Paolo Brambilla
- Department of Neurosciences and Mental Health, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Frauke Schultze-Lutter
- Department of Psychiatry and Psychotherapy, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
- University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
- Department of Psychology, Faculty of Psychology, Airlangga University, Surabaya, Indonesia
| | | | - Stephen J. Wood
- Centre for Youth Mental Health, University of Melbourne, Melbourne, Victoria, Australia
- Orygen, the National Centre of Excellence for Youth Mental Health, Melbourne, Victoria, Australia
| | - Christos Davatzikos
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Center for Biomedical Image Computing and Analytics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Rachel Upthegrove
- Institute for Mental Health and Centre for Brain Health, University of Birmingham, Birmingham, United Kingdom
- Early Intervention Service, Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, United Kingdom
| | | | - Nikolaos Koutsouleris
- Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Munich, Germany
- Max-Planck Institute of Psychiatry, Munich, Germany
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
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Luciano M, Di Vincenzo M, Brandi C, Tretola L, Toricco R, Perris F, Volpicelli A, Torella M, La Verde M, Fiorillo A, Sampogna G. Does antenatal depression predict post-partum depression and obstetric complications? Results from a longitudinal, long-term, real-world study. Front Psychiatry 2022; 13:1082762. [PMID: 36590632 PMCID: PMC9795022 DOI: 10.3389/fpsyt.2022.1082762] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 11/24/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Main aims of the present paper are to: (1) assess the prevalence of antenatal depression (AD) and identify its predictors; (2) analyse the impact of AD on obstetric outcomes and on the incidence of post-partum depression. METHODS All pregnant women referring to the Gynecology and Obstetrics inpatients unit of the University of Campania "Luigi Vanvitelli" were invited to participate. Upon acceptance, women completed the Italian version of the Edinburgh Postnatal Depression Scale and an ad-hoc questionnaire on the women's sociodemographic, gynecological and peripartum characteristics as well as their psychiatric history. Women were assessed at each trimester of pregnancy, immediately after the childbirth and after one, three, 6 and 11 months. RESULTS 268 pregnant women were recruited, with a mean of 32.2 (±5.81) years. Ninety-seven women (36.2%) reported the presence of depressive symptoms during pregnancy. Predictors of AD were personal history of depression, a family history for depressive disorders and problematic relationships with the partner. The presence of AD was associated to a reduced gestational age at the time of delivery, a lower APGAR score at 1 and 5 min, labor induction and admission of the new-born into neonatal intensive care unit. Mothers with antenatal depression are less likely to natural breastfeed. Lastly, antenatal depression was a risk factor for higher EPDS scores at follow-ups. CONCLUSIONS Our results support the idea that women should be screened during pregnancy and post-partum for the presence of depressive and anxiety symptoms. Health professionals should be adequately trained to detect psychiatric symptoms during pregnancy.
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Affiliation(s)
- Mario Luciano
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Matteo Di Vincenzo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Carlotta Brandi
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Lucia Tretola
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Rita Toricco
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Francesco Perris
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Antonio Volpicelli
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Marco Torella
- Obstetrics and Gynaecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco La Verde
- Obstetrics and Gynaecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Andrea Fiorillo
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
| | - Gaia Sampogna
- Department of Psychiatry, University of Campania "L. Vanvitelli", Naples, Italy
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