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Berns MP, Nunez GM, Zhang X, Chavan A, Zemlianova K, Mowery TM, Yao JD. Auditory decision-making deficits after permanent noise-induced hearing loss. Sci Rep 2025; 15:2104. [PMID: 39814750 PMCID: PMC11736143 DOI: 10.1038/s41598-024-83374-8] [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: 10/09/2024] [Accepted: 12/13/2024] [Indexed: 01/18/2025] Open
Abstract
Loud noise exposure is one of the leading causes of permanent hearing loss. Individuals with noise-induced hearing loss (NIHL) suffer from speech comprehension deficits and experience impairments to cognitive functions such as attention and decision-making. Here, we investigate the specific underlying cognitive processes during auditory perceptual decision-making that are impacted by NIHL. Gerbils were trained to perform an auditory decision-making task that involves discriminating between slow and fast presentation rates of amplitude-modulated (AM) noise. Decision-making task performance was assessed across pre- versus post-NIHL sessions within the same gerbils. A single exposure session (2 h) to loud broadband noise (120 dB SPL) produced permanent NIHL with elevated threshold shifts in auditory brainstem responses (ABRs). Following NIHL, decision-making task performance was tested at sensation levels comparable to those prior to noise exposure in all animals. Our findings demonstrate NIHL diminished perceptual acuity, reduced attentional focus, altered choice bias, and slowed down evidence accumulation speed. Finally, video-tracking analysis of motor behavior during task performance demonstrates that NIHL can impact sensory-guided decision-based motor execution. Together, these results suggest that NIHL impairs the sensory, cognitive, and motor factors that support auditory decision-making.
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Affiliation(s)
- Madeline P Berns
- Department of Psychology - Behavioral and Systems Neuroscience, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Genesis M Nunez
- Brain Health Institute, Rutgers, The State University of New Jersey, Nelson Biological Laboratory D418, 604 Allison Road, Piscataway, NJ, 08854, USA
| | - Xingeng Zhang
- Brain Health Institute, Rutgers, The State University of New Jersey, Nelson Biological Laboratory D418, 604 Allison Road, Piscataway, NJ, 08854, USA
| | - Anindita Chavan
- Brain Health Institute, Rutgers, The State University of New Jersey, Nelson Biological Laboratory D418, 604 Allison Road, Piscataway, NJ, 08854, USA
| | - Klavdia Zemlianova
- Zuckerman Mind Brain Behavior Institute, Columbia University, New York, NY, 10027, USA
| | - Todd M Mowery
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA
- Brain Health Institute, Rutgers, The State University of New Jersey, Nelson Biological Laboratory D418, 604 Allison Road, Piscataway, NJ, 08854, USA
| | - Justin D Yao
- Department of Otolaryngology - Head and Neck Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA.
- Brain Health Institute, Rutgers, The State University of New Jersey, Nelson Biological Laboratory D418, 604 Allison Road, Piscataway, NJ, 08854, USA.
- Department of Psychology - Behavioral and Systems Neuroscience, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA.
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Samara P, Athanasopoulos M, Markatos N, Athanasopoulos I. From sound waves to molecular and cellular mechanisms: Understanding noise‑induced hearing loss and pioneering preventive approaches (Review). MEDICINE INTERNATIONAL 2024; 4:60. [PMID: 39114262 PMCID: PMC11304036 DOI: 10.3892/mi.2024.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 07/22/2024] [Indexed: 08/10/2024]
Abstract
Noise-induced hearing loss (NIHL) is a significant and urgent global public health concern, arising from prolonged exposure to elevated levels of noise. This auditory impairment harms delicate inner ear structures, particularly the essential hair cells transmitting auditory signals to the brain. Recognized by the World Health Organization as a major contributor to worldwide hearing loss, NIHL requires a comprehensive examination of its molecular and cellular mechanisms. Animal models emerge as indispensable tools for unraveling these intricacies, allowing researchers to simulate and study the impact of noise exposure on auditory structures, shedding light on the interplay of oxidative stress, inflammation and immune responses-crucial factors in NIHL progression. The present review focuses on elucidating the molecular mechanisms of NIHL, with a specific emphasis on findings derived from animal models, alongside the exploration of thorough preventive strategies, including protective measures and probing potential interventions. Understanding the molecular underpinnings not only provides insight into targeted treatment approaches, but also unlocks pathways for exploring and implementing preventive actions. This approach not only deepens the current comprehension of NIHL, but also has the potential to influence the shaping of public health policies, offering a nuanced perspective on this prevalent auditory disorder.
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Affiliation(s)
- Pinelopi Samara
- Children's Oncology Unit ‘Marianna V. Vardinoyannis-ELPIDA’, Aghia Sophia Children's Hospital, 11527 Athens, Greece
| | | | - Nikolaos Markatos
- Otolaryngology-Head and Neck Surgery, Athens Pediatric Center, 15125 Athens, Greece
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3
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Berns MP, Nunez GM, Zhang X, Chavan A, Zemlianova K, Mowery TM, Yao JD. Auditory decision-making deficits after permanent noise-induced hearing loss. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.09.23.614535. [PMID: 39386692 PMCID: PMC11463679 DOI: 10.1101/2024.09.23.614535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Abstract
Loud noise exposure is one of the leading causes of permanent hearing loss. Individuals with noise-induced hearing loss (NIHL) suffer from speech comprehension deficits and experience impairments to cognitive functions such as attention and decision-making. Here, we tested whether a specific sensory deficit, NIHL, can directly impair auditory cognitive function. Gerbils were trained to perform an auditory decision-making task that involves discriminating between slow and fast presentation rates of amplitude-modulated (AM) noise. Decision-making task performance was assessed across pre-versus post-NIHL sessions within the same gerbils. A single exposure session (2 hours) to loud broadband noise (120 dB SPL) produced permanent NIHL with elevated threshold shifts in auditory brainstem responses (ABRs). Following NIHL, decision-making task performance was tested at sensation levels comparable to those prior to noise exposure in all animals. Our findings demonstrate NIHL diminished perceptual acuity, reduced attentional focus, altered choice bias, and slowed down evidence accumulation speed. Finally, video-tracking analysis of motor behavior during task performance demonstrates that NIHL can impact sensory-guided decision-based motor execution. Together, these results suggest that NIHL impairs the sensory, cognitive, and motor factors that support auditory decision-making.
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4
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Zhi W, Li Y, Wang Y, Zou Y, Wang H, Xu X, Ma L, Ren Y, Qiu Y, Hu X, Wang L. Effects of 90 dB pure tone exposure on auditory and cardio-cerebral system functions in macaque monkeys. ENVIRONMENTAL RESEARCH 2024; 249:118236. [PMID: 38266893 DOI: 10.1016/j.envres.2024.118236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
Excessive noise exposure presents significant health risks to humans, affecting not just the auditory system but also the cardiovascular and central nervous systems. This study focused on three male macaque monkeys as subjects. 90 dB sound pressure level (SPL) pure tone exposure (frequency: 500Hz, repetition rate: 40Hz, 1 min per day, continuously exposed for 5 days) was administered. Assessments were performed before exposure, during exposure, immediately after exposure, and at 7-, 14-, and 28-days post-exposure, employing auditory brainstem response (ABR) tests, electrocardiograms (ECG), and electroencephalograms (EEG). The study found that the average threshold for the Ⅴ wave in the right ear increased by around 30 dB SPL right after exposure (P < 0.01) compared to pre-exposure. This elevation returned to normal within 7 days. The ECG results indicated that one of the macaque monkeys exhibited an RS-type QRS wave, and inverted T waves from immediately after exposure to 14 days, which normalized at 28 days. The other two monkeys showed no significant changes in their ECG parameters. Changes in EEG parameters demonstrated that main brain regions exhibited significant activation at 40Hz during noise exposure. After noise exposure, the power spectral density (PSD) in main brain regions, particularly those represented by the temporal lobe, exhibited a decreasing trend across all frequency bands, with no clear recovery over time. In summary, exposure to 90 dB SPL noise results in impaired auditory systems, aberrant brain functionality, and abnormal electrocardiographic indicators, albeit with individual variations. It has implications for establishing noise protection standards, although the precise mechanisms require further exploration by integrating pathological and behavioral indicators.
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Affiliation(s)
- Weijia Zhi
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Ying Li
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Yuchen Wang
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Yong Zou
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Haoyu Wang
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Xinping Xu
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Lizhen Ma
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Yanling Ren
- Animal Center of the Academy of Military Medical Sciences, Beijing, China.
| | - Yefeng Qiu
- Animal Center of the Academy of Military Medical Sciences, Beijing, China.
| | - Xiangjun Hu
- Beijing Institute of Radiation Medicine, Beijing, China.
| | - Lifeng Wang
- Beijing Institute of Radiation Medicine, Beijing, China.
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5
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Ranran H, Aijie W, Yafei Z, Xinru B, Yi L, Xianghua B, Yunxin L, Guochao L, Guowei Z. Alterations of resting-state functional network connectivity in patients with noise-induced hearing loss: A study based on independent component analysis. Eur J Neurosci 2024; 59:2029-2045. [PMID: 38279577 DOI: 10.1111/ejn.16266] [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: 09/26/2023] [Revised: 12/12/2023] [Accepted: 01/12/2024] [Indexed: 01/28/2024]
Abstract
Functional reorganization is a response to auditory deficits or deprivation, and less is known about the overall brain network alterations involving resting-state networks (RSNs) and multiple functional networks in patients with occupational noise-induced hearing loss (NIHL). So this study evaluated resting-state functional network connectivity (FNC) alterations in occupational NIHL using an independent component analysis (ICA). In total, 79 mild NIHL patients (MP), 32 relatively severe NIHL patients (RSP), and 84 age- and education- matched healthy controls (HC) were recruited. All subjects were tested using the Mini-mental State Examination scale, the tinnitus Handicap Inventory scale, the Hamilton Anxiety scale (HAMA) and scanned by T1-3DFSPGR, resting-state functional magnetic resonance imaging sequence in 3.0 T and analysed by the ICA. Seven RSNs were identified, compared with the HC, the MP showed increased FNC within the executive control network (ECN) and enhanced FNC within the default mode network (DMN) and the visual network (VN); compared with the HC, the RSP showed decreased FNC within the ECN and auditory network (AUN), DMN and VN; no significant changes in FNC were found in the MP compared with the RSP. Furthermore, the correlation analysis between the noise exposure time and hearing loss level, HAMA were both negative, and there were no significant correlations between the abnormal RSNs and the hearing level, noise exposure time and HAMA. These findings indicate that different degrees of NIHL involve different alterations in RSNs connectivity and may reveal the neural mechanisms related to emotion-related features and functional abnormalities following long-term NIHL.
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Affiliation(s)
- Huang Ranran
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Wang Aijie
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Zhang Yafei
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Ba Xinru
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Lin Yi
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Bao Xianghua
- Occupational Department, Yantaishan Hospital, Yantai, China
| | - Li Yunxin
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Li Guochao
- Radiology Department, Yantaishan Hospital, Yantai, China
| | - Zhang Guowei
- Radiology Department, Yantaishan Hospital, Yantai, China
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Zhuang H, Li Q, Sun C, Xu D, Gan G, Zhang C, Chen C, Yuan Y, Liu L, Xiao Y, Yao X, Wang C, Kang X, Yang C, Zhao J, Chen W, Wang J, Li J, Luo C, Wang J, Jia X, Yu Z, Liu L. Voluntary wheel exercise ameliorates cognitive impairment, hippocampal neurodegeneration and microglial abnormalities preceded by demyelination in a male mouse model of noise-induced hearing loss. Brain Behav Immun 2023; 114:325-348. [PMID: 37683962 DOI: 10.1016/j.bbi.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/10/2023] Open
Abstract
Acquired peripheral hearing loss (APHL) in midlife has been identified as the greatest modifiable risk factor for dementia; however, the pathophysiological neural mechanisms linking APHL with an increased risk of dementia remain to be elucidated. Here, in an adult male mouse model of noise-induced hearing loss (NIHL), one of the most common forms of APHL, we demonstrated accelerated age-related cognitive decline and hippocampal neurodegeneration during a 6-month follow-up period, accompanied by progressive hippocampal microglial aberrations preceded by immediate-onset transient elevation in serum glucocorticoids and delayed-onset sustained myelin disruption in the hippocampus. Pretreatment with the glucocorticoid receptor antagonist RU486 before stressful noise exposure partially mitigated the early activation of hippocampal microglia, which were present at 7 days post noise exposure (7DPN), but had no impact on later microglial aberrations, hippocampal neurodegeneration, or cognitive decline exhibited at 1 month post noise exposure (1MPN). One month of voluntary wheel exercise following noise exposure barely affected either the hearing threshold shift or hippocampal myelin changes but effectively countered cognitive impairment and the decline in hippocampal neurogenesis in NIHL mice at 1MPN, paralleled by the normalization of microglial morphology, which coincided with a reduction in microglial myelin inclusions and a restoration of microglial hypoxia-inducible factor-1α (HIF1α) expression. Our results indicated that accelerated cognitive deterioration and hippocampal neuroplastic decline following NIHL are most likely driven by the maladaptive response of hippocampal microglia to myelin damage secondary to hearing loss, and we also demonstrated the potential of voluntary physical exercise as a promising and cost-effective strategy to alleviate the detrimental impact of APHL on cognitive function and thus curtail the high and continuously increasing global burden of dementia. Furthermore, the findings of the present study highlight the contribution of myelin debris overload to microglial malfunction and identify the microglial HIF1α-related pathway as an attractive candidate for future comprehensive investigation to obtain a more definitive picture of the underlying mechanisms linking APHL and dementia.
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Affiliation(s)
- Hong Zhuang
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Qian Li
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Congli Sun
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Dan Xu
- School of Public Health, Southeast University, Nanjing 210009, China
| | - Guangming Gan
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Chenchen Zhang
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Chen Chen
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Yang Yuan
- Department of Endocrinology, Zhongda Hospital, Medical School, Southeast University, Nanjing 210009, China
| | - Linchen Liu
- Department of Rheumatology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Yu Xiao
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Xiuting Yao
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Conghui Wang
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Xiaoming Kang
- School of Life Science and Technology, Southeast University, Nanjing 210009, China
| | - Chenxi Yang
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Jingyi Zhao
- School of Life Science and Technology, Southeast University, Nanjing 210009, China
| | - Wenhao Chen
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Jiatang Wang
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Jinyu Li
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Caichen Luo
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Jie Wang
- School of Medicine, Southeast University, Nanjing 210009, China
| | - Xirui Jia
- School of Life Science and Technology, Southeast University, Nanjing 210009, China
| | - Zhehao Yu
- Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China
| | - Lijie Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China.
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Li Q, Kang X, Liu L, Xiao Y, Xu D, Zhuang H, Liu H, Zhao J, Zou H, Yang J, Zhan X, Li T, Wang X, Liu L. Adult mice with noise-induced hearing loss exhibited temporal ordering memory deficits accompanied by microglia-associated neuroplastic changes in the medial prefrontal cortex. Neurobiol Dis 2023:106181. [PMID: 37271287 DOI: 10.1016/j.nbd.2023.106181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 05/17/2023] [Accepted: 05/30/2023] [Indexed: 06/06/2023] Open
Abstract
Acquired peripheral hearing loss in midlife is considered the primary modifiable risk factor for dementia, while the underlying pathological mechanism remains poorly understood. Excessive noise exposure is the most common cause of acquired peripheral hearing loss in modern society. This study was designed to investigate the impact of noise-induced hearing loss (NIHL) on cognition, with a focus on the medial prefrontal cortex (mPFC), a brain region that is involved in both auditory and cognitive processes and is highly affected in patients with cognitive impairment. Adult C57BL/6 J mice were randomly assigned to a control group and seven noise groups: 0HPN, 12HPN, 1DPN, 3DPN, 7DPN, 14DPN, and 28DPN, which were exposed to broadband noise at a 123 dB sound pressure level (SPL) for 2 h and sacrificed immediately (0 h), 12 h, or 1, 3, 7, 14, or 28 days post-noise exposure (HPN, DPN), respectively. Hearing assessment, behavioral tests, and neuromorphological studies in the mPFC were performed in control and 28DPN mice. All experimental animals were included in the time-course analysis of serum corticosterone (CORT) levels and mPFC microglial morphology. The results illustrated that noise exposure induced early-onset transient serum CORT elevation and permanent moderate-to-severe hearing loss in mice. 28DPN mice, in which permanent NIHL has been verified, exhibited impaired performance in temporal order object recognition tasks concomitant with reduced structural complexity of mPFC pyramidal neurons. The time-course immunohistochemical analysis in the mPFC revealed significantly higher morphological microglial activation at 14 and 28 DPN, preceded by a remarkably higher amount of microglial engulfed postsynaptic marker PSD95 at 7 DPN. Additionally, lipid accumulation in microglia was observed in 7DPN, 14DPN and 28DPN mice, suggesting a driving role of lipid handling deficits following excessive phagocytosis of synaptic elements in delayed and sustained microglial abnormalities. These findings provide fundamentally novel information concerning mPFC-related cognitive impairment in mice with NIHL and empirical evidence suggesting the involvement of microglial malfunction in the mPFC neurodegenerative consequences of NIHL.
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Affiliation(s)
- Qian Li
- Medical College, Southeast University, Nanjing 210009, China
| | - Xiaomin Kang
- School of Life Science and Technology, Southeast University, Nanjing 210096, China
| | - Linchen Liu
- Department of Rheumatology, Zhongda Hospital, Medical School of Southeast University, Nanjing 210009, China
| | - Yu Xiao
- Medical College, Southeast University, Nanjing 210009, China
| | - Dan Xu
- School of Public Health, Southeast University, Nanjing 210009, China
| | - Hong Zhuang
- Medical College, Southeast University, Nanjing 210009, China
| | - Haiqing Liu
- School of Life Science and Technology, Southeast University, Nanjing 210096, China
| | - Jingyi Zhao
- School of Life Science and Technology, Southeast University, Nanjing 210096, China
| | - Han Zou
- Medical College, Southeast University, Nanjing 210009, China
| | - Jianing Yang
- Medical College, Southeast University, Nanjing 210009, China
| | - Xindi Zhan
- Medical College, Southeast University, Nanjing 210009, China
| | - Tianxiao Li
- Medical College, Southeast University, Nanjing 210009, China
| | - Xinchen Wang
- Medical College, Southeast University, Nanjing 210009, China
| | - Lijie Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Physiology, School of Medicine, Southeast University, Nanjing 210009, China.
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Tortorella A, Menculini G, Moretti P, Attademo L, Balducci PM, Bernardini F, Cirimbilli F, Chieppa AG, Ghiandai N, Erfurth A. New determinants of mental health: the role of noise pollution. A narrative review. Int Rev Psychiatry 2022; 34:783-796. [PMID: 36786115 DOI: 10.1080/09540261.2022.2095200] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Urbanisation processes and anthropogenic actions led to a significant increase in pollution levels, with relevant consequences on global health. In particular, noise pollution demonstrated an association with cardiovascular, metabolic, and respiratory diseases. Furthermore, increasing evidence underlined the possible role of air and noise pollution in the development of psychiatric disorders. In this narrative review, evidence concerning the relationship between noise pollution and the emergence of psychiatric symptoms or psychiatric disorders is summarised. After the literature search process was completed, 40 papers were included in the present review. The exposure to road-, rail-, and air- traffic represented a risk factor for the emergence of affective disorders. This could also be mediated by the occurrence of circadian rhythms disturbances or by noise annoyance and noise sensitivity, both influencing psychological well-being and health-related quality of life. Fewer studies concentrated on special populations, particularly pregnant women and children, for whom noise pollution was confirmed as a risk factor for psychopathology. The better clarification of the complex interaction between noise pollution and mental health may help to identify subjects at risk and targeting specific prevention and intervention strategies in the urban environment.
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Affiliation(s)
| | | | | | - Luigi Attademo
- SPDC Potenza, Department of Mental Health, ASP Basilicata, Italian National Health Service, Potenza, Italy.,Planetary Health Lab, Old Medical School, University of Edinburgh, Edinburgh, UK
| | - Pierfrancesco Maria Balducci
- Department of Psychiatry, University of Perugia, Perugia, Italy.,Department of Mental Health, CSM Terni, Terni, Italy
| | - Francesco Bernardini
- Planetary Health Lab, Old Medical School, University of Edinburgh, Edinburgh, UK.,SPDC Pordenone, Department of Mental Health, AsFO Friuli Occidentale, Italian National Health Service, Pordenone, Italy
| | | | | | - Nicola Ghiandai
- Department of Psychiatry, University of Perugia, Perugia, Italy
| | - Andreas Erfurth
- 1st Department of Psychiatry and Psychotherapeutic Medicine, Wiener Gesundheitsverbund Klinik Hietzing, Vienna, Austria
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