1
|
Lv H, Guo M, Guo C, He K. The Interrelationships between Cytokines and Schizophrenia: A Systematic Review. Int J Mol Sci 2024; 25:8477. [PMID: 39126046 PMCID: PMC11313682 DOI: 10.3390/ijms25158477] [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: 05/24/2024] [Revised: 07/26/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
Schizophrenia (SCZ) imposes a significant burden on patients and their families because of its high prevalence rate and disabling nature. Given the lack of definitive conclusions regarding its pathogenesis, physicians heavily rely on patients' subjective symptom descriptions for diagnosis because reliable diagnostic biomarkers are currently unavailable. The role of the inflammatory response in the pathogenesis of SCZ has been supported by some studies. The findings of these studies showed abnormal changes in the levels of inflammatory factors, such as cytokines (CKs), in both peripheral blood and cerebrospinal fluid (CSF) among individuals affected by SCZ. The findings imply that inflammatory factors could potentially function as risk indicators for the onset of SCZ. Consequently, researchers have directed their attention towards investigating the potential utility of CKs as viable biomarkers for diagnosing SCZ. Extracellular vesicles (EVs) containing disease-specific components exhibit remarkable stability and abundance, making them promising candidates for biomarker discovery across various diseases. CKs encapsulated within EVs secreted by immune cells offer valuable insights into disease progression. This review presents a comprehensive analysis summarizing the relationship between CKs and SCZ and emphasizes the vital role of CKs encapsulated within EVs in the pathogenesis and development of SCZ.
Collapse
Affiliation(s)
- Haibing Lv
- College of Life Sciences and Food Engineering, Inner Mongolia Minzu University, Tongliao 028000, China; (H.L.); (C.G.)
| | - Meng Guo
- Finance Office, Inner Mongolia Minzu University, Tongliao 028000, China;
| | - Chuang Guo
- College of Life Sciences and Food Engineering, Inner Mongolia Minzu University, Tongliao 028000, China; (H.L.); (C.G.)
| | - Kuanjun He
- College of Life Sciences and Food Engineering, Inner Mongolia Minzu University, Tongliao 028000, China; (H.L.); (C.G.)
| |
Collapse
|
2
|
Saccaro LF, Aimo A, Panichella G, Sentissi O. Shared and unique characteristics of metabolic syndrome in psychotic disorders: a review. Front Psychiatry 2024; 15:1343427. [PMID: 38501085 PMCID: PMC10944869 DOI: 10.3389/fpsyt.2024.1343427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 02/15/2024] [Indexed: 03/20/2024] Open
Abstract
Introduction People with psychosis spectrum disorders (PSD) face an elevated risk of metabolic syndrome (MetS), which may reduce their life expectancy by nearly 20%. Pinpointing the shared and specific characteristics and clinical implications of MetS in PSD is crucial for designing interventions to reduce this risk, but an up-to-date review on MetS across the psychosis spectrum is lacking. Methods This narrative review fills this gap by examining the clinical literature on characteristics and implications of MetS in both distinct PSD and transdiagnostically, i.e., across traditional categorical diagnoses, with a focus on psychiatric and cardio-metabolic management. Results We discuss common and specific characteristics of MetS in PSD, as well as factors contributing to MetS development in PSD patients, including unhealthy lifestyle factors, genetic predisposition, pro-inflammatory state, drugs consumption, antipsychotic medication, and psychotic symptoms. We highlight the importance of early identification and management of cardio-metabolic risk in PSD patients, as well as the existing gaps in the literature, for instance in the screening for MetS in younger PSD patients. We compare hypotheses-generating clinical associations and characteristics of MetS in different PSD, concluding by reviewing the existing recommendations and challenges in screening, monitoring, and managing MetS in PSD. Conclusion Early identification and management of MetS are crucial to mitigate the long-term cardio-metabolic toll in PSD patients. Interventions should focus on healthy lifestyle and appropriate pharmacological and behavioral interventions. Further translational and clinical research is needed to develop targeted interventions and personalized treatment approaches for this vulnerable population, aiming at improving physical health and overall well-being.
Collapse
Affiliation(s)
- Luigi F Saccaro
- Psychiatry Department, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Psychiatry Department, Geneva University Hospital, Geneva, Switzerland
| | - Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Othman Sentissi
- Psychiatry Department, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Psychiatry Department, Geneva University Hospital, Geneva, Switzerland
| |
Collapse
|
3
|
Thomas M, Rakesh D, Whittle S, Sheridan M, Upthegrove R, Cropley V. The neural, stress hormone and inflammatory correlates of childhood deprivation and threat in psychosis: A systematic review. Psychoneuroendocrinology 2023; 157:106371. [PMID: 37651860 DOI: 10.1016/j.psyneuen.2023.106371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/20/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
Childhood adversity increases the risk of developing psychosis, but the biological mechanisms involved are unknown. Disaggregating early adverse experiences into core dimensions of deprivation and threat may help to elucidate these mechanisms. We therefore systematically searched the literature investigating associations between deprivation and threat, and neural, immune and stress hormone systems in individuals on the psychosis spectrum. Our search yielded 74 articles, from which we extracted and synthesized relevant findings. While study designs were heterogeneous and findings inconsistent, some trends emerged. In psychosis, deprivation tended to correlate with lower global cortical volume, and some evidence supported threat-related variation in prefrontal cortex morphology. Greater threat exposure was also associated with higher C-reactive protein, and higher and lower cortisol measures. When examined, associations in controls were less evident. Overall, findings indicate that deprivation and threat may associate with partially distinct biological mechanisms in the psychosis spectrum, and that associations may be stronger than in controls. Dimensional approaches may help disentangle the biological correlates of childhood adversity in psychosis, but more studies are needed.
Collapse
Affiliation(s)
- Megan Thomas
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne & Melbourne Health, Australia.
| | - Divyangana Rakesh
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne & Melbourne Health, Australia; Neuroimaging Department, Institute of Psychology, Psychiatry & Neuroscience, King's College London, London, United Kingdom
| | - Sarah Whittle
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne & Melbourne Health, Australia
| | - Margaret Sheridan
- Department of Psychology & Neuroscience, University of North Carolina, United States
| | - Rachel Upthegrove
- Institute for Mental Health, University of Birmingham, United Kingdom; Early Intervention Service, Birmingham Women's and Children's NHS Foundation Trust, United Kingdom
| | - Vanessa Cropley
- Melbourne Neuropsychiatry Centre, Department of Psychiatry, The University of Melbourne & Melbourne Health, Australia
| |
Collapse
|
4
|
Foiselle M, Lajnef M, Hamdani N, Boukouaci W, Wu CL, Naamoune S, Chami L, Mezoued E, Richard JR, Bouassida J, Sugunasabesan S, Le Corvoisier P, Barrau C, Yolken R, Leboyer M, Tamouza R. Immune cell subsets in patients with bipolar disorder or schizophrenia with history of childhood maltreatment. Brain Behav Immun 2023; 112:42-50. [PMID: 37263365 DOI: 10.1016/j.bbi.2023.05.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 05/06/2023] [Accepted: 05/25/2023] [Indexed: 06/03/2023] Open
Abstract
A history of Childhood Maltreatment (CM) has been repeatedly associated with an increased risk of developing bipolar disorders (BD) or schizophrenia (SZ). The impact of severe stress induced by CM has been proposed to be mediated by elevated inflammation reflected by dysregulated inflammatory processes. Little is known about the potential impact of CM on lymphocyte subpopulations or the role of pre-existing infections on CM physiological consequences. This study therefore explored the role of CM and past infection exposure impact on lymphocyte subpopulations to give an indication of their relevance as stressors in the pathoetiology of major mood and psychotic disorders. 118 adult patients with SZ, and 152 with BD were included in the analysis. CM history was assessed by the Childhood Trauma Questionnaire (CTQ), with current and past psychiatric symptomatology also evaluated. Circulating immune cell subsets were analyzed using flow cytometry-based analysis. Past exposure to common infectious stigma including toxoplasma, cytomegalovirus (CMV) and Epstein-Barr virus (EBV) were measured by solid phase-enzyme microplate and ELISA immunoassays. The relationship between CM, biological phenotypes (including immune cell subsets distribution and past infectious status) and clinical phenotypes were analyzed using univariate and multivariate analyses. BD patients with, versus without, CM had higher levels of CD3+CD8+ cytotoxic T cells and CMV antibodies along with decreased levels of CD45RA+CCR7+CD8+ naïve CD8+ T cells, and a more severe clinical profile. CMV antibody levels were inversely associated with the CD3 + CD8 + lymphocyte subset level. SZ patients with, versus without, CM, showed lower levels of CD14 + monocytes and no specific clinical characteristics. The accumulation of different types of maltreatment associated with increased body mass index and CMV autoantibodies as well as decreased levels of CD14 + monocytes. In both BD and SZ, further analysis according to the type and the number of CM subtypes showed association with specific changes in lymphocyte cell subsets, clinical profile, and infectious stigma. Adults with BD or SZ exposed to CM exhibit specific immune cell subset profiles, clinical features, and stigma of past infections. In BD, our data indicate an interplay between CM and CMV infections, which may possibly contribute to premature aging and cellular senescence, both of which have previously been shown to associate with mood disorders. Longitudinal studies of CM-exposed patients are required to clarify the interactions of CM and viral infections, including as to the pathophysiological processes driving patient symptomatology.
Collapse
Affiliation(s)
- Marianne Foiselle
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Mohamed Lajnef
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Nora Hamdani
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Wahid Boukouaci
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Ching-Lien Wu
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Soumia Naamoune
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Leïla Chami
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Esma Mezoued
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Jean-Romain Richard
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Jihène Bouassida
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Sobika Sugunasabesan
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Philippe Le Corvoisier
- Inserm, Centre d'Investigation Clinique 1430 et AP-HP, Hôpitaux Universitaires Henri Mondor, Univ Paris Est Creteil, F-94010 Créteil, France
| | - Caroline Barrau
- Plateforme de Ressources Biologiques, HU Henri Mondor, AP-HP, Créteil F94010, France
| | - Robert Yolken
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Marion Leboyer
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| | - Ryad Tamouza
- Université Paris-Est Créteil (UPEC), INSERM, IMRB, Translational Neuropsychiatry, AP-HP, Hôpitaux Universitaires H. Mondor, DMU IMPACT, Fédération Hospitalo-Universitaire de Médecine de Précision en Psychiatrie (FHU ADAPT), Fondation FondaMental, F-94010 Créteil, France
| |
Collapse
|
5
|
Chen XY, Chan KL, Lo CKM, Ho FK, Leung WC, Ip P. The association between victimization and inflammation: A meta-analysis. J Affect Disord 2023; 323:108-122. [PMID: 36435395 DOI: 10.1016/j.jad.2022.11.063] [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: 01/21/2022] [Revised: 11/11/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND To meta-analyze the existing studies examining the association of childhood and adulthood victimization with inflammation and to explore the moderating variables that affect these relationships. METHODS Relevant work published before 28th February 2021 was identified by searching five major databases. We analyzed the cross-sectional data extracted from cross-sectional and longitudinal studies using the random-effects model to estimate the correlation (r) as the pooled effect size and further conducted subgroup analyses and sensitivity analyses. RESULTS A total of 37 articles finally met the inclusion criteria, including studies for C-reactive protein (CRP) (k = 23; NCRP = 11,780), interleukin-6 (IL-6) (k = 31; NIL-6 = 8943), and tumor necrosis factor-alpha (TNF-α) (k = 14; NTNF-α = 4125). Overall, victimization has a significantly positive association with inflammation, with a small effect size (r = 0.122). Specifically, effect sizes were the largest for TNF-a (r = 0.152), followed by IL-6 (r = 0.119), and CRP (r = 0.084). Additionally, the effect sizes for victimization against children were r = 0.145 (k = 6) for childhood victimization - childhood inflammation, and r = 0.139 (k = 27) for childhood victimization - adulthood inflammation, which appear to be larger than that of victimization against adults (r = 0.039; k = 2). LIMITATIONS Only a small number of studies on adult victimization were included. In addition, we only analyzed the cross-sectional relationship and did not have sufficient data to compare different types of victimization and single vs. multiple victimizations. CONCLUSIONS Victimization is associated with a heightened inflammatory response. As victimization against children may have a stronger effect than victimization against adults, prevention of victimization targeting the childhood period may be necessary. Studies with more robust methodologies (i.e., representative, longitudinal, and multi-country designs) are needed to confirm these findings and to unpack the underlying mechanisms.
Collapse
Affiliation(s)
- Xiao-Yan Chen
- Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Ko Ling Chan
- Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong.
| | - Camilla K M Lo
- Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Frederick K Ho
- Institute of Health and Wellbeing, University of Glasgow, 1 Lilybank Gardens, Glasgow G12 8RZ, United Kingdom
| | - Wing Cheong Leung
- Department of Obstetrics & Gynaecology, Kwong Wah Hospital, Kowloon, Hong Kong
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Pokfulam, Hong Kong
| |
Collapse
|
6
|
Marques-Feixa L, Palma-Gudiel H, Romero S, Moya-Higueras J, Rapado-Castro M, Castro-Quintas Á, Zorrilla I, José Muñoz M, Ramírez M, Mayoral M, Mas A, José Lobato M, Blasco-Fontecilla H, Fañanás L. Childhood maltreatment disrupts HPA-axis activity under basal and stress conditions in a dose-response relationship in children and adolescents. Psychol Med 2023; 53:1060-1073. [PMID: 34269169 PMCID: PMC9976019 DOI: 10.1017/s003329172100249x] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 03/31/2021] [Accepted: 06/03/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND This study investigates the impact of childhood maltreatment (CM) on hypothalamic-pituitary-adrenal (HPA)-axis functioning and on anxiety perception. Moreover, the influence of CM severity and frequency was also explored. METHODS In total, 187 participants aged 7-17 were assessed for CM history using validated questionnaires and ad hoc interviews to be classified according to the criteria of the Tool for Assessing the Severity of Situations in which Children are Vulnerable (TASSCV). Psychopathology was ascertained using the K-SADS-PL5. To assess HPA-axis functioning, salivary cortisol samples were collected throughout a normal day and during an acute psychosocial stressor, the Trier Social Stress Test for children (TSST-C). Subjective anxiety was evaluated using STAI/-C. RESULTS Youth with a CM history had higher overall diurnal cortisol levels (p = 0.001), blunted cortisol response to acute psychosocial stress (p = 0.002) and greater perceived anxiety (p = 0.003), than those without CM. Specifically, participants exposed to moderate/severe or often/frequent CM showed the greater diurnal cortisol output (pseverity = 0.002; pfrequency = 0.003), and blunted cortisol response during the TSST-C (pseverity = 0.006; pfrequency = 0.008). Meanwhile, youth with low CM severity/frequency exhibited a similar cortisol response to those without CM. However, perceived anxiety was higher in those exposed to CM (p < 0.001), regardless of its severity/frequency. CONCLUSIONS Disturbances in HPA-axis functioning are already evident early after CM exposure, while psychological and physiological responses to an acute stressor are dissociated in youth exposed to CM. The dose-response relationship described in this paper highlights the need to comprehensively evaluate CM so that vulnerable children can be identified and assigned to proper interventions.
Collapse
Affiliation(s)
- Laia Marques-Feixa
- Department of Evolutionary Biology, Ecology and Environmental Sciences, Faculty of Biology, University of Barcelona, Biomedicine Institute of the University of Barcelona (IBUB), Barcelona, Spain
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
| | - Helena Palma-Gudiel
- Department of Evolutionary Biology, Ecology and Environmental Sciences, Faculty of Biology, University of Barcelona, Biomedicine Institute of the University of Barcelona (IBUB), Barcelona, Spain
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
| | - Soledad Romero
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic de Barcelona, 2017SGR88, Barcelona, Spain
- Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Jorge Moya-Higueras
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Psychology, Faculty of Education, Psychology and Social Work, University of Lleida, Spain
| | - Marta Rapado-Castro
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, Madrid, Spain
- Department of Psychiatry, Melbourne Neuropsychiatry Centre, The University of Melbourne & Melbourne Health, Victoria, Australia
| | - Águeda Castro-Quintas
- Department of Evolutionary Biology, Ecology and Environmental Sciences, Faculty of Biology, University of Barcelona, Biomedicine Institute of the University of Barcelona (IBUB), Barcelona, Spain
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
| | - Iñaki Zorrilla
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Psychiatry, Hospital Santiago Apostol, Vitoria-Gasteiz, Spain
| | - María José Muñoz
- Hospital Benito Menni, Adolescent Crisis Unit, Sant Boi de Llobregat, Spain
| | - Maite Ramírez
- Galdakao Mental Health Services, Child and Adolescent Mental Health, Galdakao, Spain
| | - María Mayoral
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry and Mental Health, Hospital General Universitario Gregorio Marañón, School of Medicine, Universidad Complutense, IiSGM, Madrid, Spain
| | - Ariadna Mas
- Department of Child and Adolescent Psychiatry and Psychology, Institute of Neuroscience, Hospital Clínic de Barcelona, 2017SGR88, Barcelona, Spain
| | - María José Lobato
- Department of Psychiatry, Puerta de Hierro University Hospital-Majadahonda, Autonoma University, ITA Mental Health, Madrid, Spain
| | - Hilario Blasco-Fontecilla
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
- Department of Psychiatry, Puerta de Hierro University Hospital-Majadahonda, Autonoma University, ITA Mental Health, Madrid, Spain
| | - Lourdes Fañanás
- Department of Evolutionary Biology, Ecology and Environmental Sciences, Faculty of Biology, University of Barcelona, Biomedicine Institute of the University of Barcelona (IBUB), Barcelona, Spain
- Network Centre for Biomedical Research in Mental Health (CIBER of Mental Health, CIBERSAM), Spain
| | | |
Collapse
|
7
|
Miljevic C, Munjiza-Jovanovic A, Jovanovic T. Impact of Childhood Adversity, as Early Life Distress, on Cytokine Alterations in Schizophrenia. Neuropsychiatr Dis Treat 2023; 19:579-586. [PMID: 36938321 PMCID: PMC10015972 DOI: 10.2147/ndt.s396168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/23/2023] [Indexed: 03/21/2023] Open
Abstract
Even though inflammation theory has been introduced in the pathophysiology of psychosis almost a century ago, many of its aspects have remained unelucidated. Numerous studies have shown cytokine dysregulation in schizophrenia and a predominance of pro-inflammatory cytokines, but on another side, various cytokines in a pro-inflammatory group have different trends in all subtypes of schizophrenia. Alterations are also present in anti-inflammatory and regulatory cytokines, but findings are still not consistent. On the other hand, it is well known that abuse and neglect in childhood may be predictors of psychotic disorders, and childhood adversity is also associated with alterations of the immune and inflammatory response (through various mechanisms including HPA dysregulation as well). This review aims to analyze conducted studies and elucidate the link between childhood abuse, schizophrenia, and cytokine alterations. Putting together this complex psycho-immunological puzzle for the subgroup of schizophrenia-diagnosed patients with distinct immunological abnormalities and a history of childhood abuse can help us to answer the question about the future treatment of these patients.
Collapse
Affiliation(s)
- Cedo Miljevic
- Department of Psychiatry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Clinical Trial Unit, Institute of Mental Health, Belgrade, Serbia
- Correspondence: Cedo Miljevic, Department of Psychiatry, Faculty of Medicine, University of Belgrade, Milana Kasanina 3, Belgrade, 11 000, Serbia, Tel +381 11 3307500, Fax +381 33 40 629, Email
| | - Ana Munjiza-Jovanovic
- Department of Psychiatry, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Day Hospital for Adolescents, Institute of Mental Health, Belgrade, Serbia
| | - Teodora Jovanovic
- Department for Psychotic Disorders, Institute of Mental Health, Belgrade, Serbia
| |
Collapse
|
8
|
Lestra V, Romeo B, Martelli C, Benyamina A, Hamdani N. Could CRP be a differential biomarker of illness stages in schizophrenia? A systematic review and meta-analysis. Schizophr Res 2022; 246:175-186. [PMID: 35785580 DOI: 10.1016/j.schres.2022.06.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Revised: 05/13/2022] [Accepted: 06/22/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with schizophrenia display peripheral inflammation but the impact of illness phase is not clear. Our meta-analysis investigated the difference in CRP levels between patients with schizophrenia and controls according to their illness phase. METHODS After a systematic search, all studies measuring CRP in patients with schizophrenia and controls were included. Standardized mean differences were calculated between patients and controls according to illness phase. The influence of sociodemographic and clinical variables on our results was investigated using a meta-regression analysis. RESULTS Fifty studies were included in this meta-analysis. Patients with schizophrenia had higher CRP levels than controls in the acute (p < 0.00001) and stable (p < 0.00001) stage of their disease. Patients with acute exacerbation of schizophrenia had higher CRP levels than stable patients (p = 0.02) but this difference did not persist when considering antipsychotic-medicated patients in both phases. Meta-regressions found that the increase of CRP in acutely ill patients as compared to controls was influenced by age (p < 0.01), BMI (p = 0.01) and first episode (p = 0.02), whereas the increase in CRP levels of stable patients as compared to controls was moderated by BMI (p = 0.004). CONCLUSIONS In conclusion, this meta-analysis provides strong evidence that patients with schizophrenia have higher CRP levels than controls, but also show an increase in inflammatory response in the acute stage of the disease as compared to the stable stage. CRP could thus be considered as a state marker and a trait marker of the disease.
Collapse
Affiliation(s)
- V Lestra
- APHP, Paul Brousse Hospital, Department of Psychiatry and Addictology, F-94800 Villejuif, France; Unité Psychiatrie-Comorbidités-Addictions, PSYCOMADD 4872, Université Paris-Sud - AP-HP, Université Paris Saclay, France
| | - B Romeo
- APHP, Paul Brousse Hospital, Department of Psychiatry and Addictology, F-94800 Villejuif, France; Unité Psychiatrie-Comorbidités-Addictions, PSYCOMADD 4872, Université Paris-Sud - AP-HP, Université Paris Saclay, France.
| | - C Martelli
- APHP, Paul Brousse Hospital, Department of Psychiatry and Addictology, F-94800 Villejuif, France; Unité Psychiatrie-Comorbidités-Addictions, PSYCOMADD 4872, Université Paris-Sud - AP-HP, Université Paris Saclay, France; Institut National de la Santé et de la Recherche Médicale U1299, Research unit, NeuroImaging and Psychiatry, Paris Sud University, Paris Saclay University, Paris Descartes University, Digiteo Labs, Bâtiment 660, Gif-sur-Yvette, France
| | - A Benyamina
- APHP, Paul Brousse Hospital, Department of Psychiatry and Addictology, F-94800 Villejuif, France; Unité Psychiatrie-Comorbidités-Addictions, PSYCOMADD 4872, Université Paris-Sud - AP-HP, Université Paris Saclay, France
| | - N Hamdani
- Unité Psychiatrie-Comorbidités-Addictions, PSYCOMADD 4872, Université Paris-Sud - AP-HP, Université Paris Saclay, France; Cédiapsy, 87 rue d'Assas, 75006 Paris, France
| |
Collapse
|
9
|
Lippard ETC, Nemeroff CB. Going beyond risk factor: Childhood maltreatment and associated modifiable targets to improve life-long outcomes in mood disorders. Pharmacol Biochem Behav 2022; 215:173361. [PMID: 35219755 DOI: 10.1016/j.pbb.2022.173361] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/17/2022] [Accepted: 02/20/2022] [Indexed: 01/26/2023]
Abstract
Childhood maltreatment increases risk for mood disorders and is associated with earlier onset-and more pernicious disease course following onset-of mood disorders. While the majority of studies to date have been cross-sectional, longitudinal studies are emerging and support the devastating role(s) childhood maltreatment has on development of, and illness course in, mood disorders. This manuscript extends prior reviews to emphasize more recent work, highlighting longitudinal data, and discusses treatment studies that provide clues to mechanisms that mediate disease risk, course, relapse, and treatment response. Evidence suggesting systemic inflammation, alterations in hypothalamic-pituitary-adrenal (HPA) axis function and corticotropin-releasing factor (CRF) neural systems, genetic and other familial factors as mechanisms that mediate risk and onset of, and illness course in, mood disorders following childhood maltreatment is discussed. Risky behaviors following maltreatment, e.g., substance use and unhealthy lifestyles, may further exacerbate alterations in the HPA axis, CRF neural systems, and systematic inflammation to contribute to a more pernicious disease course. More research on sex differences and the impact of maltreatment in vulnerable populations is needed. Future research needs to be aimed at leveraging knowledge on modifiable targets, going beyond childhood maltreatment as a risk factor, to inform prevention and treatment strategies and foster trauma-informed care.
Collapse
Affiliation(s)
- Elizabeth T C Lippard
- Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas, Austin, TX, USA; Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX, USA; Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX, USA; Department of Psychology, University of Texas, Austin, TX, USA; Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX, USA.
| | - Charles B Nemeroff
- Department of Psychiatry and Behavioral Sciences, Dell Medical School, University of Texas, Austin, TX, USA; Institute of Early Life Adversity Research, Dell Medical School, University of Texas, Austin, TX, USA; Waggoner Center for Alcohol and Addiction Research, University of Texas, Austin, TX, USA; Mulva Clinic for Neuroscience, Dell Medical School, University of Texas, Austin, TX, USA
| |
Collapse
|
10
|
Li J, Zhang G, Wang J, Liu D, Wan C, Fang J, Wu D, Zhou Y, Tian T, Zhu W. Experience-dependent associations between distinct subtypes of childhood trauma and brain function and architecture. Quant Imaging Med Surg 2022; 12:1172-1185. [PMID: 35111614 DOI: 10.21037/qims-21-435] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 08/31/2021] [Indexed: 11/06/2022]
Abstract
Background Childhood trauma can alter brain-development trajectories and lead to a greater risk of psychopathology developing in adulthood. For this reason, understanding experience-dependent brain abnormalities associated with different trauma subtypes is crucial for identifying developmental processes disrupted by unfavorable early environments and for proposing early intervention measures to reduce trauma's negative effects. Methods This study used multimodal magnetic resonance imaging (MRI) to explore the neural correlates of distinct subtypes of childhood trauma. We recruited a large community sample of young adults (mean age, 24.1, SD 1.9 years) who completed a Childhood Trauma Questionnaire, were given behavioral scores, and underwent multimodal MRI. To quantify brain changes, we used functional connectivity density (FCD) mapping based on whole brain analysis, regions of interest (ROI) analysis, and morphological measurements. Experience-dependent brain abnormalities were identified by multivariable linear regression. Results We found that diverse brain regions in the FCD mapping were significantly related to 4 trauma subtypes and belonged to different cognitive components used for various behaviors. Experience-related influences on functional circuits and brain morphology were observed in extensive regions, including the sensorimotor, cingulum, accumbens, insula, and frontal-parietal areas, as well as in regions within the default mode network. Conclusions Identifying specific regions or systems may be a valid strategy for understanding the pathogenesis and development process of psychiatric disorders in people with different traumatic experiences and may facilitate better-targeted intervention strategies for maltreated children.
Collapse
Affiliation(s)
- Jia Li
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guiling Zhang
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jian Wang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Dong Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Changhua Wan
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jicheng Fang
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Di Wu
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiran Zhou
- Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tian Tian
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenzhen Zhu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| |
Collapse
|
11
|
Brown M, Worrell C, Pariante CM. Inflammation and early life stress: An updated review of childhood trauma and inflammatory markers in adulthood. Pharmacol Biochem Behav 2021; 211:173291. [PMID: 34695507 DOI: 10.1016/j.pbb.2021.173291] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 10/10/2021] [Accepted: 10/13/2021] [Indexed: 10/20/2022]
Abstract
Inflammation, as a neurobiological consequence of childhood trauma, has frequently been reported across research, however, recent investigations suggest this relationship may be dependent on specificities such as type of trauma, type of inflammatory marker, and additional mediatory variables - such as body mass index (BMI), age, and sex. As an updated version of a previous review by Baumeister et al., the current review comprised a search of PubMed, which identified 37 articles that collectively assessed 4 inflammatory markers (CRP, IL-6, TNFα and IL-1β). A review of the studies revealed predominantly non-significant associations between childhood trauma and elevated levels of all inflammatory markers in adulthood. However, in line with previous research, discrepancies in significance arose when considering type of trauma, type of inflammatory marker, and additional variables. Compared to neglect, abuse showed greater significant associations with elevated inflammatory markers in adulthood, though this was dependent on the individual subtypes (emotional, physical or sexual). Mediation analyses reported BMI as a significant mediator, though, when controlled for, no significant differences were found. Sex differences were reported but investigations were sparse. Future research should investigate the mediatory role of sex differences in the inflammatory effects of childhood trauma. Many studies in the review were restricted by use of the same trauma measure - the Childhood Trauma Questionnaire. To assess greater variety of trauma types, future studies should utilize other standardized measures to explore these avenues.
Collapse
Affiliation(s)
- Mollie Brown
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Courtney Worrell
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| | - Carmine M Pariante
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, London, UK.
| |
Collapse
|
12
|
Peripheral levels of C-reactive protein, tumor necrosis factor-α, interleukin-6, and interleukin-1β across the mood spectrum in bipolar disorder: A meta-analysis of mean differences and variability. Brain Behav Immun 2021; 97:193-203. [PMID: 34332041 DOI: 10.1016/j.bbi.2021.07.014] [Citation(s) in RCA: 77] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 06/21/2021] [Accepted: 07/22/2021] [Indexed: 01/17/2023] Open
Abstract
IMPORTANCE It is unclear whether differences exist in the magnitude and variability of pro-inflammatory mediators in the different phases of bipolar disorder (BD) and among subjects with BD, as compared to healthy controls. OBJECTIVE To run a comparative meta-analysis of C-Reactive Protein (CRP), IL-1, IL-6, TNF-α in BD vs healthy controls, measuring mean and variability effects on all subjects. Sensitivity analyses include disease activity. DATA SOURCES Systematic review of observational studies in PubMed and PsycInfo up to February 2nd, 2020. STUDY SELECTION Case-control studies reporting inflammatory mediators' levels in BD and controls. DATA EXTRACTION AND SYNTHESIS Summary distribution measures of circulating CRP, IL-1β, IL-6, TNF-α in participants with BD and control groups were extracted. Random-effects multivariate meta-analyses were conducted based on individual study/mediator effect sizes (Hedge's g). MAIN OUTCOMES AND MEASURES Co-primary outcomes were inflammatory mediators' levels (Hedge's g) and variability (coefficient of variance ratio (CVR)) differences between participants with BD across the mood spectrum and controls. RESULTS Out of the initial 729 papers, 72 were assessed and then excluded after full-text review, and ultimately 53 studies were included in the systematic review, while 49 were included in the meta-analysis. The mean age was 36.96 (SD: 9.29) years, and the mean female percentage was 56.31 (SD: 16.61). CRP (g = 0.70, 95% CI 0.31-1.09, k = 37, BD = 2,215 vs HC = 3,750), IL-6 (g = 0.81, 95% CI 0.46-1.16, k = 45, BD = 1,956 vs HC = 4,106), TNF-α (g = 0.49, 95% CI 0.19-0.78, k = 49, BD = 2,231 vs HC = 3,017) were elevated in subjects with BD vs HC, but not IL-1β (g = -0.28, 95% CI -0.68-0.12, k = 4, BD = 87 vs HC = 66). When considering euthymic, depressive, and manic episodes separately, CRP and TNF-α were elevated in both depressive and manic episodes, but not in euthymia, while IL-6 remained elevated regardless of the disease state. No difference in CVR emerged for CRP, IL-1β, and TNF-α, while a lower CVR was observed for IL-6. When considering disease phases, CVR was higher in BD than in HCs for CRP during depressive episodes, lower for IL-6 during euthymia, and higher during manic episodes for CRP, IL-6, and TNF-α. Sensitivity analyses after excluding outliers identified with funnel plot visual inspection, low-quality studies, and considering only studies matched per body mass index confirmed the main results. Meta-regression showed that age (IL-6, TNF-α), gender (CRP), duration of illness (CRP) moderated elevated individual inflammatory levels. CONCLUSIONS AND RELEVANCE Peripheral pro-inflammatory marker elevations were confirmed in BD. CRP and TNF-α could represent state markers, as they were only elevated during mood episodes, while IL-6 appeared to be a trait marker for BD. Increased variability of specific inflammatory mediators in specific disease active states suggests that a subset of subjects with BD may exhibit elevated inflammation as part of a manic or depressive episode.
Collapse
|
13
|
Tamouza R, Meyer U, Foiselle M, Richard JR, Wu CL, Boukouaci W, Le Corvoisier P, Barrau C, Lucas A, Perron H, Leboyer M. Identification of inflammatory subgroups of schizophrenia and bipolar disorder patients with HERV-W ENV antigenemia by unsupervised cluster analysis. Transl Psychiatry 2021; 11:377. [PMID: 34230451 PMCID: PMC8260666 DOI: 10.1038/s41398-021-01499-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/26/2021] [Accepted: 06/21/2021] [Indexed: 02/06/2023] Open
Abstract
Human endogenous retroviruses (HERVs) are remnants of infections that took place several million years ago and represent around 8% of the human genome. Despite evidence implicating increased expression of HERV type W envelope (HERV-W ENV) in schizophrenia and bipolar disorder, it remains unknown whether such expression is associated with distinct clinical or biological characteristics and symptoms. Accordingly, we performed unsupervised two-step clustering of a multivariate data set that included HERV-W ENV protein antigenemia, serum cytokine levels, childhood trauma scores, and clinical data of cohorts of patients with schizophrenia (n = 29), bipolar disorder (n = 43) and healthy controls (n = 32). We found that subsets of patients with schizophrenia (~41%) and bipolar disorder (~28%) show positive antigenemia for HERV-W ENV protein, whereas the large majority (96%) of controls was found to be negative for ENV protein. Unsupervised cluster analysis identified the presence of two main clusters of patients, which were best predicted by the presence or absence of HERV-W ENV protein. HERV-W expression was associated with increased serum levels of inflammatory cytokines and higher childhood maltreatment scores. Furthermore, patients with schizophrenia who were positive for HERV-W ENV protein showed more manic symptoms and higher daily chlorpromazine (CPZ) equivalents, whereas HERV-W ENV positive patients with bipolar disorder were found to have an earlier disease onset than those who were negative for HERV-W ENV protein. Taken together, our study suggest that HERV-W ENV protein antigenemia and cytokines can be used to stratify patients with major mood and psychotic disorders into subgroups with differing inflammatory and clinical profiles.
Collapse
Affiliation(s)
- Ryad Tamouza
- AP-HP, Hôpital Henri Mondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), Fédération Hospitalo-Universitaire de Médecine de Précision (FHU ADAPT), Créteil, France.
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France.
- Fondation FondaMental, Créteil, France.
| | - Urs Meyer
- Institute of Pharmacology and Toxicology, University of Zurich-Vetsuisse, Zurich, Switzerland
- Neuroscience Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Marianne Foiselle
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France
- Fondation FondaMental, Créteil, France
| | - Jean-Romain Richard
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France
- Fondation FondaMental, Créteil, France
| | - Ching-Lien Wu
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France
- Fondation FondaMental, Créteil, France
| | - Wahid Boukouaci
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France
- Fondation FondaMental, Créteil, France
| | - Philippe Le Corvoisier
- Université Paris Est Créteil, Centre Investigation Clinique, CIC Henri Mondor, Créteil, France
| | - Caroline Barrau
- Plateforme de Ressources Biologiques, HU Henri Mondor, Créteil, France
| | - Alexandre Lucas
- Institut des Maladies Métaboliques et Cardiovasculaires (I2MC), plateau We-Met, Inserm UMR1048 and Université Paul Sabatier, Toulouse, France
| | - Hervé Perron
- GeNeuro, 3, Chemin du pré Fleuri 1228 Plan-les-Ouates, Geneva, Switzerland
- Université de Lyon-UCBL, Lyon, France
| | - Marion Leboyer
- AP-HP, Hôpital Henri Mondor, Département Médico-Universitaire de Psychiatrie et d'Addictologie (DMU IMPACT), Fédération Hospitalo-Universitaire de Médecine de Précision (FHU ADAPT), Créteil, France.
- Université Paris Est Créteil, Laboratoire Neuro-Psychiatrie translationnelle, Créteil, France.
- Fondation FondaMental, Créteil, France.
| |
Collapse
|
14
|
The association of child maltreatment and systemic inflammation in adulthood: A systematic review. PLoS One 2021; 16:e0243685. [PMID: 33831008 PMCID: PMC8031439 DOI: 10.1371/journal.pone.0243685] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
Introduction Child maltreatment (CM) is associated with mental and physical health disorders in adulthood. Some studies have identified elevated markers of systemic inflammation in adult survivors of CM, and inflammation may mediate the association between CM and later health problems. However, there are methodological inconsistencies in studies of the association between CM and systemic inflammation and findings are conflicting. We performed a systematic review to examine the association of CM with systemic inflammation in adults. Methods A pre-registered systematic review was performed following PRISMA guidelines. Medline, Embase, Scopus and PsychInfo were searched for studies of the association of CM with blood markers of inflammation in adults. Quality was assessed using the Crowe Critical Appraisal Tool. We had intended to perform a meta-analysis, but this was not possible due to variation in study design and reporting. Results Forty-four articles met criteria for inclusion in the review. The most widely reported biomarkers were C-Reactive Protein (CRP) (n = 27), interleukin-6 (IL-6) (n = 24) and Tumour Necrosis Factor-alpha (TNF-a) (n = 17). Three studies were prospective (all relating to CRP) and the remainder were retrospective. 86% of studies were based in high income countries. In the prospective studies, CM was associated with elevated CRP in adulthood. Results of retrospective studies were conflicting. Methodological issues relating to the construct of CM, methods of analysis, and accounting for confounding or mediating variables (particularly Body Mass Index) may contribute to the uncertainty in the field. Conclusions There is some robust evidence from prospective studies that CM is associated with elevated CRP in adulthood. We have identified significant methodological inconsistencies in the literature and have proposed measures that future researchers could employ to improve consistency across studies. Further prospective, longitudinal, research using robust and comparable measures of CM with careful consideration of confounding and mediating variables is required to bring clarity to this field.
Collapse
|
15
|
Quidé Y, Bortolasci CC, Spolding B, Kidnapillai S, Watkeys OJ, Cohen-Woods S, Carr VJ, Berk M, Walder K, Green MJ. Systemic inflammation and grey matter volume in schizophrenia and bipolar disorder: Moderation by childhood trauma severity. Prog Neuropsychopharmacol Biol Psychiatry 2021; 105:110013. [PMID: 32540496 DOI: 10.1016/j.pnpbp.2020.110013] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/28/2020] [Accepted: 06/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Elevated levels of systemic inflammation are consistently reported in both schizophrenia (SZ) and bipolar-I disorder (BD), and are associated with childhood trauma exposure. We tested whether childhood trauma exposure moderates associations between systemic inflammation and brain morphology in people with these diagnoses. METHODS Participants were 55 SZ cases, 52 BD cases and 59 healthy controls (HC) who underwent magnetic resonance imaging. Systemic inflammation was measured using a composite z-score derived from serum concentrations of interleukin 6, tumor necrosis factor alpha and C-reactive protein. Indices of grey matter volume covariation (GMC) were derived from independent component analysis. Childhood trauma was measured using the Childhood Trauma Questionnaire (CTQ Total score). RESULTS A series of moderated moderation analyses indicated that increased systemic inflammation were associated with increased GMC in the striatum and cerebellum among all participants. Severity of childhood trauma exposure moderated the relationship between systemic inflammation and GMC in one component, differently among the groups. Specifically, decreased GMC in the PCC/precuneus, parietal lobule and postcentral gyrus, and increased GMC in the left middle temporal gyrus was associated with increased systemic inflammation in HC individuals exposed to high (but not low or average) levels of trauma and in SZ cases exposed to low (but not average or high) levels of trauma, but not in BD cases. CONCLUSIONS Increased systemic inflammation is associated with grey matter changes in people with psychosis, and these relationships may be partially and differentially moderated by childhood trauma exposure according to diagnosis.
Collapse
Affiliation(s)
- Yann Quidé
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia; Neuroscience Research Australia, Randwick, NSW, Australia.
| | - Chiara C Bortolasci
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Briana Spolding
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Srisaiyini Kidnapillai
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, VIC, Australia
| | - Oliver J Watkeys
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia; Neuroscience Research Australia, Randwick, NSW, Australia
| | - Sarah Cohen-Woods
- Discipline of Psychology, Flinders University, Adelaide, SA, Australia; Flinders Centre for Innovation in Cancer, Adelaide, SA, Australia; Órama Institute, College of Education, Psychology, and Social Work, Flinders University, Adelaide, SA, Australia
| | - Vaughan J Carr
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia; Neuroscience Research Australia, Randwick, NSW, Australia; Department of Psychiatry, School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Michael Berk
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, VIC, Australia; Deakin University, IMPACT, the Institute for Mental and Physical Health and Clinical Translation, Barwon Health, Geelong, VIC, Australia; Florey Institute for Neuroscience and Mental Health, Parkville, VIC, Australia; Orygen, The National Centre of Excellence in Youth Mental Health, Parkville, VIC, Australia; Department of Psychiatry, University of Melbourne, Parkville, VIC, Australia
| | - Ken Walder
- Centre for Molecular and Medical Research, School of Medicine, Deakin University, Geelong, VIC, Australia; Deakin University, IMPACT, the Institute for Mental and Physical Health and Clinical Translation, Barwon Health, Geelong, VIC, Australia
| | - Melissa J Green
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia; Neuroscience Research Australia, Randwick, NSW, Australia
| |
Collapse
|
16
|
Abstract
In this chapter, we will focus on childhood maltreatment and its role in the vulnerability to BD.We will review how childhood maltreatment and trauma not only predispose to the development of BD but also to a more unstable, pernicious, and severe clinical expression of the disorder. This environmental risk factor is suggested to be part of a multiple hit model of vulnerability, involving not only early stressors (prenatal and postnatal ones) but also interactions with the genetic background of individuals and with other stressors occurring later in life. We will also review how childhood maltreatment and trauma may modify the brain functioning and circuits and alter some biological pathways in BD, hence leading to psychopathology. Finally, we will briefly discuss the implications for clinical practice and treatment.
Collapse
Affiliation(s)
- Bruno Etain
- Université de Paris, Paris, France.
- INSERM U1144, Faculté de Pharmacie de Paris, Université de Paris, Paris, France.
- Assistance Publique des Hôpitaux de Paris P-HP, GHU Saint-Louis - Lariboisière - F. Widal, Département de Psychiatrie et de Médecine Addictologique, Paris, France.
| | - Monica Aas
- NORMENT, Division of Mental Health and Addiction, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
17
|
Ouyang H, Huang M, Xu Y, Yao Q, Wu X, Zhou D. Reduced Cell-Free Mitochondrial DNA Levels Were Induced by Antipsychotics Treatment in First-Episode Patients With Schizophrenia. Front Psychiatry 2021; 12:652314. [PMID: 34305669 PMCID: PMC8292716 DOI: 10.3389/fpsyt.2021.652314] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 06/07/2021] [Indexed: 11/13/2022] Open
Abstract
Cell-free mitochondrial DNA (cf-mtDNA) is a damage-associated molecular pattern that boosts the release of cytokines and induces the immune response of the body; therefore, it is closely related to mental diseases. This study aims to evaluate a potential link between cf-mtDNA and clinical progression in first-episode patients with schizophrenia. In this study, plasma cf-mtDNA levels in 34 first-episode patients with schizophrenia before and after 8 weeks of antipsychotic treatment were examined. In addition, the clinical progression of first-episode schizophrenia was assessed using the Positive and Negative Syndrome Scale (PANSS). The copy number changes in the plasma cf-mtDNA (Δcf-mtDNA) were significantly correlated with changes in the PANSS scale scores (ΔPANSS) in first-episode patients with schizophrenia (ΔPANSS total score, P = 0.002; ΔPANSS positive score, P = 0.01). Plasma cf-mtDNA may represent a relevant tool in the future to assist in the assessment of clinical progression in first-episode patients with schizophrenia.
Collapse
Affiliation(s)
- Houxian Ouyang
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China.,Department of Laboratory Diagnostics, Ningbo Kangning Hospital, Ningbo, China
| | - Minfang Huang
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China.,Department of Pharmacology, Ningbo Kangning Hospital, Ningbo, China
| | - Yongming Xu
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China
| | - Qin Yao
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China.,Ningbo Key Laboratory of Sleep Medicine, Ningbo, China
| | - Xiangping Wu
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China
| | - Dongsheng Zhou
- Department of Psychiatry, Ningbo Kangning Hospital, Ningbo, China.,Ningbo Key Laboratory of Sleep Medicine, Ningbo, China
| |
Collapse
|
18
|
Fischer KF, Simon MS, Elsner J, Dobmeier J, Dorr J, Blei L, Zill P, Obermeier M, Musil R. Assessing the links between childhood trauma, C-reactive protein and response to antidepressant treatment in patients with affective disorders. Eur Arch Psychiatry Clin Neurosci 2021; 271:1331-1341. [PMID: 33733300 PMCID: PMC8429368 DOI: 10.1007/s00406-021-01245-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 02/24/2021] [Indexed: 12/12/2022]
Abstract
Adverse Childhood Experiences (ACE) are a well-known risk-factor for depression. Additionally, (high-sensitive) C-reactive Protein (hsCRP) is elevated in subgroups of depressed patients and high following ACE. In this context the literature considers hsCRP and ACE to be associated with treatment resistant depression. With the data being heterogenous, this study aimed to explore the associations of ACE, hsCRP levels and response to antidepressant treatment in uni- and bipolar depression. N = 76 patients diagnosed with uni- or bipolar depression and N = 53 healthy controls were included. Treatment was over 6 weeks in an inpatient psychiatric setting within an observatory study design. Depressive symptoms were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS), ACE were assessed by the Childhood Trauma Questionnaire (CTQ); the body-mass-index (BMI) and hsCRP were measured. HsCRP levels did not differ between the study population and the healthy controls. While the depressive symptoms decreased, the hsCRP levels increased. Sexual abuse was associated with significant higher and emotional abuse with lower levels of hsCRP after 6 weeks. The baseline hsCRP levels and the ACE subgroups did not show significant associations with the treatment response in unipolar depressed patients. The long-lasting effects of specific forms of ACE may have relevant impact on inflammation, supporting hsCRP to be a suitable biomarker. With ACE and hsCRP not showing any significant associations with treatment response in the unipolar depressed subgroup, a more differentiate research concerning biomarkers and treatment regimens is needed when talking about treatment response.
Collapse
Affiliation(s)
- Kai F. Fischer
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nußbaumstraße 7, 80336 München, Germany
| | - Maria S. Simon
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nußbaumstraße 7, 80336 München, Germany
| | - Julie Elsner
- grid.17091.3e0000 0001 2288 9830Institute of Mental Health at UBC, University of British Columbia, Vancouver, Canada
| | | | | | - Leonie Blei
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nußbaumstraße 7, 80336 München, Germany
| | - Peter Zill
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nußbaumstraße 7, 80336 München, Germany
| | | | - Richard Musil
- grid.5252.00000 0004 1936 973XDepartment of Psychiatry and Psychotherapy, University Hospital, LMU Munich, Nußbaumstraße 7, 80336 München, Germany
| |
Collapse
|
19
|
Quidé Y, Tozzi L, Corcoran M, Cannon DM, Dauvermann MR. The Impact of Childhood Trauma on Developing Bipolar Disorder: Current Understanding and Ensuring Continued Progress. Neuropsychiatr Dis Treat 2020; 16:3095-3115. [PMID: 33364762 PMCID: PMC7751794 DOI: 10.2147/ndt.s285540] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/18/2020] [Indexed: 12/12/2022] Open
Abstract
Childhood trauma (CT) has been repeatedly linked to earlier onset and greater severity of bipolar disorder (BD) in adulthood. However, such knowledge is mostly based on retrospective and cross-sectional studies in adults with BD. The first objective of this selective review is to characterize the short-term effects of CT in the development of BD by focusing on studies in young people. The second objective is to describe the longer-term consequences of CT by considering studies with adult participants. This review first outlines the most prominent hypotheses linking CT exposure and the onset of BD. Then, it summarizes the psychological and biological risk factors implicated in the development of BD, followed by a discussion of original studies that investigated the role of CT in young people with early-onset BD, youths at increased risk of developing BD, or young people with BD with a focus on subclinical and clinical outcome measures. The review considers additional biological and psychological factors associated with a negative impact of CT on the long-term course of BD in later adulthood. Finally, we discuss how the integration of information of CT can improve ongoing early identification of BD and mitigate severe clinical expression in later adulthood.
Collapse
Affiliation(s)
- Yann Quidé
- School of Psychiatry, University of New South Wales (UNSW), Sydney, NSW, Australia
- Neuroscience Research Australia, Randwick, NSW, Australia
| | - Leonardo Tozzi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Mark Corcoran
- School of Psychology, National University of Ireland Galway, Galway, Ireland
| | - Dara M Cannon
- Centre for Neuroimaging & Cognitive Genomics (NICOG), Clinical Neuroimaging Laboratory, NCBES Galway Neuroscience Centre, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Maria R Dauvermann
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- McGovern Institute for Brain Research, Massachusetts Institute of Technology, Cambridge, MA, USA
| |
Collapse
|
20
|
Piotrowski P, Frydecka D, Kotowicz K, Stańczykiewicz B, Samochowiec J, Szczygieł K, Misiak B. A history of childhood trauma and allostatic load in patients with psychotic disorders with respect to stress coping strategies. Psychoneuroendocrinology 2020; 115:104645. [PMID: 32171901 DOI: 10.1016/j.psyneuen.2020.104645] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/03/2020] [Accepted: 03/03/2020] [Indexed: 12/14/2022]
Abstract
Elevated allostatic load (AL) index, which is a cumulative measure of biological dysregulations associated with stress exposure, has been demonstrated in patients with psychosis. However, it remains unknown whether a history of childhood trauma (CT) might contribute to elevated AL index in psychosis. Therefore, we aimed to investigate the association between AL index, a history of CT and coping styles in patients with psychotic disorders. Participants were 65 patients with schizophrenia-spectrum disorders and 56 healthy controls (HCs). The AL index was computed based on percentile distributions of 15 biomarkers in HCs. The AL index was significantly higher in patients with psychosis. A history of parental antipathy was associated with elevated AL index in both groups of participants. A history of any categories of CT and sexual abuse were associated with higher AL index only in patients with psychosis. Social diversion (seeking social interactions in case of stressful experiences) mediated the association between sexual abuse and the AL index in the group of patients. There was a significant direct effect of sexual abuse on the AL index (this specific CT was associated with higher AL index). However, indirect effect of sexual trauma on AL through social diversion was opposite to direct effect. Childhood adversities, especially sexual abuse and parental antipathy, might contribute to elevated AL index in patients with psychosis. The effect of sexual abuse on the AL index might be specific to psychosis. Engagement in social interactions in case of stressful situations might alleviate biological dysregulations associated with CT.
Collapse
Affiliation(s)
- Patryk Piotrowski
- Department of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
| | - Dorota Frydecka
- Department of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
| | - Kamila Kotowicz
- Department of Psychiatry, Wroclaw Medical University, Pasteura 10 Street, 50-367 Wroclaw, Poland
| | - Bartłomiej Stańczykiewicz
- Department of Nervous System Diseases, Wroclaw Medical University, Bartla 5 Street, 51-618 Wroclaw, Poland
| | - Jerzy Samochowiec
- Department of Psychiatry, Pomeranian Medical University, Broniewskiego 26 Street, 71-460 Szczecin, Poland
| | - Krzysztof Szczygieł
- Department of Psychiatry, Pomeranian Medical University, Broniewskiego 26 Street, 71-460 Szczecin, Poland
| | - Błażej Misiak
- Department of Genetics, Wroclaw Medical University, Marcinkowskiego 1 Street, 50-368 Wroclaw, Poland.
| |
Collapse
|
21
|
Cardozo PL, de Lima IBQ, Maciel EMA, Silva NC, Dobransky T, Ribeiro FM. Synaptic Elimination in Neurological Disorders. Curr Neuropharmacol 2020; 17:1071-1095. [PMID: 31161981 PMCID: PMC7052824 DOI: 10.2174/1570159x17666190603170511] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 04/23/2019] [Accepted: 05/31/2019] [Indexed: 12/12/2022] Open
Abstract
Synapses are well known as the main structures responsible for transmitting information through the release and recognition of neurotransmitters by pre- and post-synaptic neurons. These structures are widely formed and eliminated throughout the whole lifespan via processes termed synaptogenesis and synaptic pruning, respectively. Whilst the first pro-cess is needed for ensuring proper connectivity between brain regions and also with the periphery, the second phenomenon is important for their refinement by eliminating weaker and unnecessary synapses and, at the same time, maintaining and fa-voring the stronger ones, thus ensuring proper synaptic transmission. It is well-known that synaptic elimination is modulated by neuronal activity. However, only recently the role of the classical complement cascade in promoting this phenomenon has been demonstrated. Specifically, microglial cells recognize activated complement component 3 (C3) bound to synapses tar-geted for elimination, triggering their engulfment. As this is a highly relevant process for adequate neuronal functioning, dis-ruptions or exacerbations in synaptic pruning could lead to severe circuitry alterations that could underlie neuropathological alterations typical of neurological and neuropsychiatric disorders. In this review, we focus on discussing the possible in-volvement of excessive synaptic elimination in Alzheimer’s disease, as it has already been reported dendritic spine loss in post-synaptic neurons, increased association of complement proteins with its synapses and, hence, augmented microglia-mediated pruning in animal models of this disorder. In addition, we briefly discuss how this phenomenon could be related to other neurological disorders, including multiple sclerosis and schizophrenia.
Collapse
Affiliation(s)
- Pablo L Cardozo
- Laboratório de Neurobioquímica, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Izabella B Q de Lima
- Laboratório de Neurobioquímica, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Esther M A Maciel
- Laboratório de Neurobioquímica, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Nathália C Silva
- Laboratório de Neurobioquímica, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Fabíola M Ribeiro
- Laboratório de Neurobioquímica, Departamento de Bioquímica e Imunologia, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| |
Collapse
|
22
|
Barraza F, Arancibia M, Madrid E, Papuzinski C. General concepts in biostatistics and clinical epidemiology: Random error and systematic error. Medwave 2019; 19:e7687. [PMID: 31584929 DOI: 10.5867/medwave.2019.07.7687] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/05/2019] [Indexed: 11/27/2022] Open
Abstract
Biomedical research, particularly when it involves human beings, is always subjected to sources of error that must be recognized. Systematic error or bias is associated with problems in the methodological design or during the execu-tion phase of a research project. It affects its validity and is qualitatively ap-praised. On the other hand, random error is related to variations due to chance. It may be quantitatively expressed, but never removed. This review is the first of a methodological series on general concepts in biostatistics and clin-ical epidemiology developed by the Chair of Scientific Research Methodology at the School of Medicine, University of Valparaíso, Chile. In this article, we address the theoretical concepts of error, its evaluation, and control. Finally, we discuss some current controversies in its conceptualization that are relevant to undergraduate and graduate students of health sciences.
Collapse
Affiliation(s)
- Felipe Barraza
- Cátedra de Metodología de la Investigación Científica, Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile. ORCID: 0000-0002-7677-9378
| | - Marcelo Arancibia
- Cátedra de Metodología de la Investigación Científica, Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile; Centro Interdisciplinario de Estudios en Salud (CIESAL), Universidad de Valparaíso, Valparaíso, Chile. ORCID: 0000-0003-2239-6248
| | - Eva Madrid
- Cátedra de Metodología de la Investigación Científica, Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile; Centro Interdisciplinario de Estudios en Salud (CIESAL), Universidad de Valparaíso, Valparaíso, Chile. ORCID: 0000-0002-8095-5549
| | - Cristian Papuzinski
- Cátedra de Metodología de la Investigación Científica, Escuela de Medicina, Universidad de Valparaíso, Valparaíso, Chile; Centro Interdisciplinario de Estudios en Salud (CIESAL), Universidad de Valparaíso, Valparaíso, Chile. ORCID: 0000-0002-0080-4506. Address: Angamos 655 Oficina 110, Reñaca, Viña del Mar, Chile. EMail:
| |
Collapse
|