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Strube W, Wagner E, Luykx JJ, Hasan A. A review on side effect management of second-generation antipsychotics to treat schizophrenia: a drug safety perspective. Expert Opin Drug Saf 2024; 23:715-729. [PMID: 38676922 DOI: 10.1080/14740338.2024.2348561] [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: 11/09/2023] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
INTRODUCTION Effective side effects management present a challenge in antipsychotic treatment with second-generation antipsychotics (SGAs). In recent years, most of the commonly used SGAs, except for clozapine, have been shown to differ only slightly in their effectiveness, but considerably regarding perceived side effects, safety profiles, and compatibility to preexisting medical conditions. AREAS COVERED The current state of available evidence on side-effect management in SGA treatment of patients with schizophrenia spectrum disorders (SSD) is reviewed. In addition, current guideline recommendations are summarized, highlighting evidence gaps. EXPERT OPINION SGA safety and side effects needs to be considered in treatment planning. Shared decision-making assistants (SDMA) can support patients, practitioners and relatives to orient their decisions toward avoiding side effects relevant to patients' adherence. Alongside general measures like psychosocial and psychotherapeutic care, switching to better tolerated SGAs can be considered a relatively safe strategy. By contrast, novel meta-analytical evidence emphasizes that dose reduction of SGAs can statistically increase the risk of relapse and other unfavorable outcomes. Further, depending on the type and severity of SGA-related side effects, specific treatments can be used to alleviate induced side effects (e.g. add-on metformin to reduce weight-gain). Finally, discontinuation should be reserved for acute emergencies.
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Affiliation(s)
- Wolfgang Strube
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
| | - Elias Wagner
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
- Evidence-based psychiatry and psychotherapy, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Jurjen J Luykx
- Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, the Netherlands
- Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Outpatient second opinion clinic, GGNet Mental Health, Warnsveld, The Netherlands
| | - Alkomiet Hasan
- Department of Psychiatry, Psychosomatics and Psychotherapy, University of Augsburg, Augsburg, Germany
- DZPG (German Center for Mental Health), partner site München/Augsburg, Augsburg, Germany
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Shettima FB, Wakil MA, Sheikh TL, Abdulaziz M, Rabbebe IB, Wakawa IA, Placidus O. Prevalence and correlates of sexual dysfunction among patients with schizophrenia spectrum disorder on antipsyhotic medications in Maiduguri, Northeastern Nigeria. Int J Psychiatry Med 2024; 59:373-392. [PMID: 37616598 DOI: 10.1177/00912174231196612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Abstract
OBJECTIVES Despite the importance of a satisfying sexual life, most patients with schizophrenia spectrum disorders do not discuss sexual issue with their clinicians. The current study seeks to determine the prevalence and socio-clinical correlates of sexual dysfunction among patients with schizophrenia spectrum disorders receiving typical and atypical antipsychotic medications. The second objective is to determine the frequency and correlates of specific sexual dysfunction (desire, arousal, erection/lubrication and orgasm) by gender and drug type using the Arizona Sexual Experience Scale. METHODOLOGY This cross-sectional study used standardized structured interviewer based survey to assess sexual dysfunction among patients with schizophrenia that are both sexually active and inactive at a tertiary hospital in Maiduguri from December 2020 to April 2021. Participants were also assayed for prolactin using ELISA Kit for a possible association with sexual dysfunction. RESULTS The overall prevalence of sexual dysfunction among patients with schizophrenia spectrum disorder receiving antipsychotics was 34% with patients on typical and atypical antipsychotics reporting rates of 36.8% and 24.6%, respectively. Among the typical and atypical antipsychotics, patients receiving haloperidol (40.3%) and risperidone (37.5%) reported a relatively higher frequency of sexual dysfunction compared to those receiving clozapine (18.2%). Independent correlates of sexual dysfunction were: female gender (OR = 1.89, 95% CI = 1.17-3.06; P = .010), being unmarried (OR = 1.51, 95% CI = 1.17-1.96; P = .001), pseudoparkinsonism (OR = 1.66, 95% CI = 1.02-2.69; P = .008), prolactin (OR = 2.15, 95% CI = 1.34-3.43; P = .001) and severity of illness (OR = 1.34, 95% CI = 1.03-1.75; P = .030). CONCLUSION Sexual dysfunction is prevalent among patients with schizophrenia spectrum disorder receiving either typical or atypical antipsychotics.
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Affiliation(s)
- Falmata Baba Shettima
- Departmental of Mental Health, Federal Neuropsychiatric Hospital Maiduguri, Maiduguri, Nigeria
| | - Musa Abba Wakil
- Departmental of Mental Health, Federal Neuropsychiatric Hospital Maiduguri, Maiduguri, Nigeria
| | | | | | - Isa Bukar Rabbebe
- Departmental of Mental Health, Federal Neuropsychiatric Hospital Maiduguri, Maiduguri, Nigeria
| | - Ibrahim Abdu Wakawa
- Departmental of Mental Health, Federal Neuropsychiatric Hospital Maiduguri, Maiduguri, Nigeria
| | - Ogualili Placidus
- Departmental of Mental Health, Federal Neuropsychiatric Hospital Maiduguri, Maiduguri, Nigeria
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Sales I, AlRuthia Y. Arabic translation and cultural adaptation of Hill-Bone compliance to high blood pressure therapy scale. Saudi Pharm J 2024; 32:102053. [PMID: 38590609 PMCID: PMC10999866 DOI: 10.1016/j.jsps.2024.102053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024] Open
Abstract
Background Adherence to prescription medications is vital to the success of any treatment plan, especially for chronic health conditions, such as hypertension (HTN). Although there are different scales used in assessing adherence to prescription medications, most if not all, of those scales are not available in Arabic. The absence of essential assessment tools makes the appraisal of adherence to prescription medications very difficult for native Arabic speakers. Therefore, this study aimed to translate and validate the Hill-Bone Compliance to High Blood Pressure Therapy (CHBPT) scale, which is commonly used to assess adherence to antihypertensive medications, among a sample of Arabic-speaking patients with HTN. Methods This was a single-center cross-sectional study that took place at a university-affiliated hospital. It interviewed adult (≥18 years) patients with HTN who were visiting the primary care clinics between January and November 2020. Non-Arabic speakers, those under 18 years of age, individuals without a diagnosis of HTN, and patients without any previously filled prescription medications for HTN within the past three months were excluded. The forward-backward translation method was used after receiving permission from the originators of the questionnaire to translate their scale to Arabic. Test-retest and Cronbach alpha methods were used to assess the reliability. Principal component analysis with varimax rotation was used to examine the construct validity. Results One hundred and forty-one patients consented and participated in the study. Most of the patients were ≥ 50 years old (75 %), male (72 %), and had another chronic health condition besides HTN (99 %). The translated scale had good internal consistency (Cronbach alpha = 0.83) and reliability (intraclass correlation coefficient of 0.9). The Kaiser-Meyer-Oklin was 0.82 indicating adequate sampling to conduct factor analysis; hence, three factors (e.g., subscales) were extracted similar to the original scale. The mean scores for appointment keeping, medication taking, and reducing sodium intake subscales, as well as for the overall scale were 5.62 ± 1.39, 33.94 ± 3.87, 9.73 ± 2.1, and 49.29 ± 5.21, respectively. Conclusion The translated version of the Hill-Bone CHBPT scale has both good reliability and validity and will hopefully help healthcare providers assess and monitor HTN patients' adherence to their antihypertensive medication regimens. Multicenter studies should be conducted to verify the validity and reliability of the translated questionnaire among different Arabic-speaking patient populations with HTN.
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Affiliation(s)
- Ibrahim Sales
- Department of Clinical Pharmacy, College of Pharmacy, Riyadh, Saudi Arabia
| | - Yazed AlRuthia
- Department of Clinical Pharmacy, College of Pharmacy, Riyadh, Saudi Arabia
- Pharmacoeconomics Research Unit, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Solmi M, Lähteenvuo M, Tanskanen A, Corbeil O, Mittendorfer-Rutz E, Correll CU, Tiihonen J, Taipale H. Antipsychotic Use and Risk of Breast Cancer in Women With Severe Mental Illness: Replication of a Nationwide Nested Case-Control Database Study. Schizophr Bull 2024:sbae058. [PMID: 38687213 DOI: 10.1093/schbul/sbae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND HYPOTHESIS Breast cancer is more prevalent in women with severe mental illness than in the general population, and use of prolactin-increasing antipsychotics may be a contributing factor. STUDY DESIGN A nested case-control study was conducted using the Swedish nationwide registers (inpatient/outpatient care, sickness absence, disability pension, prescribed drugs, cancers). All women aged 18-85 years with schizophrenia/schizoaffective/other nonaffective psychotic disorder/bipolar disorder and breast cancer (cases) were matched for age, primary psychiatric diagnosis, and disease duration with five women without cancer (controls). The association between cumulative exposure to prolactin-increasing/prolactin-sparing antipsychotics and breast cancer was analyzed using conditional logistic regression, adjusted for comorbidities and co-medications. STUDY RESULTS Among 132 061 women, 1642 (1.24%) developed breast cancer between 2010 and 2021, at a mean age of 63.3 ± 11.8 years. Compared with 8173 matched controls, the odds of breast cancer increased in women with prior exposure to prolactin-increasing antipsychotics for 1-4 years (adjusted odds ratio [aOR] = 1.20, 95% confidence interval [CI] = 1.03-1.41), and for ≥ 5 years (aOR = 1.47, 95%CI = 1.26-1.71). There were no increased or decreased odds of breast cancer with exposure to prolactin-sparing antipsychotics of either 1-4 years (aOR = 1.17, 95%CI = 0.98-1.40) or ≥5 years (aOR = 0.99, 95%CI = 0.78-1.26). The results were consistent across all sensitivity analyses (ie, according to different age groups, cancer types, and primary psychiatric diagnosis). CONCLUSIONS Although causality remains uncertain, exposure to prolactin-elevating antipsychotics for ≥ 1 year was associated with increased odds of breast cancer in women with severe mental illness. When prescribing antipsychotics, a shared decision-making process should consider individual risk factors for breast cancer.
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Affiliation(s)
- Marco Solmi
- Department of Psychiatry, University of Ottawa, Ontario, Canada
- SCIENCES LAB, Department of Mental Health, The Ottawa Hospital, Ontario, Canada
- Ottawa Hospital Research Institute (OHRI), Clinical Epidemiology Program, University of Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ontario, Canada
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
| | - Markku Lähteenvuo
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
| | - Antti Tanskanen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Olivier Corbeil
- Faculty of Pharmacy, Université Laval, Quebec, Canada
- Department of Pharmacy, Quebec Mental Health University Institute, Quebec, Canada
| | | | - Christoph U Correll
- Department of Child and Adolescent Psychiatry, Charité Universitätsmedizin, Berlin, Germany
- Department of Psychiatry, The Zucker Hillside Hospital, Glen Oaks, NY
- Department of Psychiatry and Molecular Medicine, Donald and Barbara School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Jari Tiihonen
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
| | - Heidi Taipale
- Department of Forensic Psychiatry, University of Eastern Finland, Niuvanniemi Hospital, Kuopio, Finland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center for Psychiatry Research, Stockholm City Council, Stockholm, Sweden
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Korchia T, Achour V, Faugere M, Albeash A, Yon DK, Boyer L, Fond G. Sexual Dysfunction in Schizophrenia: A Systematic Review and Meta-Analysis. JAMA Psychiatry 2023; 80:1110-1120. [PMID: 37703012 PMCID: PMC10500435 DOI: 10.1001/jamapsychiatry.2023.2696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 06/04/2023] [Indexed: 09/14/2023]
Abstract
Importance In individuals with schizophrenia, antipsychotic-induced dysfunctions are frequent but often underexplored in clinical practice. Objective To synthetize the data of observational studies exploring the prevalence of sexual dysfunction in individuals with schizophrenia-spectrum disorders as well as associated factors. Data Sources A systematic literature search without language or time restrictions was conducted in Google, Google Scholar, PubMed/MEDLINE, Science Direct, and Université Sorbonne Paris Cité for studies published up to June 8, 2022. Study Selection All observational studies reporting a prevalence of sexual dysfunction in schizophrenia-spectrum disorder were included. Data Extraction and Synthesis The MOOSE guidelines with independent extraction by 2 observers and random-effects models were used. Main Outcomes and Measures The prevalence of sexual dysfunction and each specific dysfunction. Results A total of 72 of 1119 studies from 33 countries on 6 continents published from inception to June 2022 were included with a total of 21 076 participants with schizophrenia. The pooled global prevalence of sexual dysfunctions was 56.4% (95% CI, 50.5-62.2), with a prevalence of 55.7% (95% CI, 48.1-63.1) for men and 60.0% (95% CI, 48.0-70.8) for women. The most frequent sexual dysfunction was erectile dysfunction in men (44%; 95% CI, 33.5-55.2), followed by loss of libido in men (41%; 95% CI, 30.7-51.4), ejaculation dysfunction in men (39%; 95% CI, 26.8-51.8), orgasm dysfunction in women (28%; 95% CI, 18.4-40.2), and amenorrhea in women (25%; 95% CI, 17.3-35.0). Factors associated with heterogeneity were study design, time and location, sociodemographic data, alcohol use disorder, psychiatric diagnosis, illness severity, and the use of antidepressants and anxiolytics. Sexual dysfunctions were more frequent in schizophrenia vs schizoaffective disorders, and erectile disorders were less frequent in individuals with longer illness duration. Antidepressant and mood stabilizer prescriptions were associated with lower rates of erection disorders (β, -6.30; 95% CI, -10.82 to -1.78); P = .006 and -13.21; 95% CI, -17.59 to -8.83; P < .001, respectively) and ejaculation disorders (β, -6.10; 95% CI, -10.68 to -1.53; P = .009 and β, -11.57; 95% CI, -16.34 to -6.80; P < .001, respectively). No obvious improvements in the rates of sexual dysfunction at other times were found, and there were conflicting results regarding antipsychotic classes. Conclusions and Relevance This systematic review and meta-analysis found a high prevalence of sexual dysfunction among individuals with schizophrenia, with considerable heterogeneity in associated factors. The findings also suggest that some dysfunctions may be explained by schizophrenia. The association between lower rates of dysfunction and antidepressant use suggests that treating comorbid depression could be an effective strategy to improve sexual health. A lack of data on metabolic parameters and physical health in general was also noted, while these issues are frequent in the care of schizophrenia.
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Affiliation(s)
- Théo Korchia
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Vincent Achour
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Mélanie Faugere
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- FondaMental Foundation, Creteil, France
| | - Ali Albeash
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
| | - Dong Keon Yon
- Department of Pediatrics, Kyung Hee University College of Medicine, Seoul, Republic of Korea
- Center for Digital Health, Medical Science Research Institute, Kyung Hee University Medical Center, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Laurent Boyer
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- FondaMental Foundation, Creteil, France
| | - Guillaume Fond
- Assistance Publique-Hopitaux de Marseille, Aix-Marseille University, CEReSS - Health Service Research and Quality of Life Center, Marseille, France
- FondaMental Foundation, Creteil, France
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Angelaki M, Alexiou E, Igoumenou A, Alevizopoulos G. Frequency of sexual dysfunction in outpatients with severe mental illness in Greece. Front Psychiatry 2023; 14:1227218. [PMID: 37720899 PMCID: PMC10503055 DOI: 10.3389/fpsyt.2023.1227218] [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: 05/22/2023] [Accepted: 08/14/2023] [Indexed: 09/19/2023] Open
Abstract
Introduction Patients with psychosis can develop sexual dysfunction, which may be related to the disease itself, psychosocial factors, somatic comorbidities, and the use of psychotropic medication. Objective We aimed to investigate the type and frequency of sexual dysfunction in patients diagnosed with schizophrenia or bipolar disorder in order to assess the side effects of antipsychotics in sexual function. Methods This is a multicenter, cross-sectional study, involving patients diagnosed with schizophrenia (79.3%) or bipolar disorder (20.7%) treated in the Department of Psychiatry and Community Mental Health Centers from November 2018 to December 2019. Patients were enrolled in the study after signed informed consent. Demographic and clinical data were collected from patients through a semi-structured interview. The Antipsychotics and Sexual Functioning Questionnaire (ASFQ) was administered to assess sexual function. Results A total of 87 outpatients on antipsychotics were recruited in the study. The mean age was 43.6 years, while the mean duration of the disease was 16.9 years. Overall, only 9.1% of patients spontaneously reported sexual dysfunction. Patients treated with oral first-generation antipsychotics had more difficulties in achieving orgasm and decreased erection capacity. In contrast, patients treated with oral second-generation antipsychotics had decreased ejaculation capacity. Patients on antipsychotic combination therapy were associated with higher rates of sexual anhedonia. Discussion These results suggest that sexual dysfunction is a side effect of antipsychotic treatment, which was spontaneously rarely reported by patients. It seems essential to obtain a psychosexual clinical history before initiating antipsychotic treatment to evaluate following changes and adopt an individualized strategy to manage sexual dysfunction induced by antipsychotics.
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Affiliation(s)
- Maria Angelaki
- Department of Education, 251 Hellenic Air Force Hospital, Athens, Greece
| | - Eirini Alexiou
- Forensic Psychiatric Clinic, Sahlgrenska University Hospital, Gothenburg, Sweden
- Center for Ethics, Law, and Mental Health (CELAM), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Artemis Igoumenou
- Division of Psychiatry, University College London, London, United Kingdom
| | - Giorgos Alevizopoulos
- Department of Psychiatry, Agioi Anargyroi Hospital, Faculty of Nursing, National and Kapodistrian University of Athens, Athens, Greece
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Thana LJ, O'Connell L, Carne-Watson A, Shastri A, Saravanamuthu A, Budhwani N, Jayacodi S, Leeson VC, Munjiza J, Pappa S, Hughes E, Reilly J, Crawford MJ. Barriers to the management of sexual dysfunction among people with psychosis: analysis of qualitative data from the REMEDY trial. BMC Psychiatry 2022; 22:545. [PMID: 35953808 PMCID: PMC9373458 DOI: 10.1186/s12888-022-04193-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND More than half of people who use antipsychotic medication for psychosis report having sexual dysfunction. The REMEDY trial aimed to find out if switching antipsychotic medication provides an effective way to reduce sexual dysfunction among people with psychosis. We set out to recruit 216 participants over a two-year period, but recruitment was stopped after an extended 12-month pilot phase, during which we recruited only 10 participants. As part of a nested process evaluation, we conducted qualitative interviews with front-line clinicians to examine barriers to recruitment to the trial. METHODS We developed a semi-structured interview schedule to explore staff views on factors that influenced whether they referred potential participants to the study. We interviewed a purposive sample of 51 staff from four National Health Service (NHS) Trusts in England, ensuring a range of different backgrounds, seniority, and levels of involvement in the trial. Audio recordings of interviews were transcribed for verbatim, and data were analysed using an inductive approach to thematic analysis. RESULTS Nine interconnected themes were generated. Six themes concerned barriers to recruitment; including; prioritising patients' mental stability, mutual discomfort and embarrassment about discussing a "taboo" subject, and concerns about unintended consequences of asking people with psychosis about their sexual functioning. Three themes, including the quality of treatment relationships and strategies for opening dialogue suggested ways to improve recognition of these "hidden" side effects. CONCLUSION The identification and management of sexual dysfunction among people with psychosis are not priorities for mental health services in England at this time. Many staff working in front-line services feel unprepared and uncomfortable asking people with psychosis about these problems. While greater use of screening tools may improve the identification of sexual dysfunction among people with psychosis, the evaluation and implementation of interventions to manage them will continue to be challenging unless NHS leaders and senior clinicians demonstrate greater commitment to changing current clinical practice. TRIAL REGISTRATION Current Controlled Trials ISRCTN12307891.
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Affiliation(s)
- Lavanya J Thana
- Division of Psychiatry, Commonwealth Building, Imperial College London, Du Cane Road, London, W12 0NN, UK
| | - Lesley O'Connell
- Division of Psychiatry, Commonwealth Building, Imperial College London, Du Cane Road, London, W12 0NN, UK
| | | | | | | | | | - Sandra Jayacodi
- Central and North West London NHS Foundation Trust, London, UK
| | - Verity C Leeson
- Division of Psychiatry, Commonwealth Building, Imperial College London, Du Cane Road, London, W12 0NN, UK
| | - Jasna Munjiza
- Central and North West London NHS Foundation Trust, London, UK
| | | | - Elizabeth Hughes
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Joe Reilly
- Tees, Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Mike J Crawford
- Division of Psychiatry, Commonwealth Building, Imperial College London, Du Cane Road, London, W12 0NN, UK.
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Martínez-Giner G, Giménez-De Llano E, Romero-Rubio D, Abad-Pérez MJ, Sánchez-Martínez V. Sexual dysfunction in people treated with long-acting injectable antipsychotics in monotherapy or polypharmacy: a naturalistic study. Int J Ment Health Nurs 2022; 31:576-590. [PMID: 34973049 DOI: 10.1111/inm.12973] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 11/22/2021] [Accepted: 12/12/2021] [Indexed: 01/28/2023]
Abstract
Sexual dysfunction, psychosis, and antipsychotics are known to be related, but the precise association between them is still unknown. Most evidence about the prevalence of sexual dysfunction in people treated with antipsychotic drugs comes from studies with restrictive samples. That is why our main objective was to determine the prevalence of sexual dysfunction in a real-life sample of outpatients treated with antipsychotics, considering gender. A cross-sectional naturalistic study was developed, including people treated with long-acting injectable antipsychotics, with or without other psychotropic drugs. Participants were interviewed to assess sexual satisfaction through a Likert scale (0 to 10) and the presence of sexual dysfunction (the Psychotropic-Related Sexual Dysfunction Questionnaire, PRSexDQ-SALSEX). The participants also had a blood test to determine prolactin (men and women) and testosterone levels (men only). A total of 131 people participated in the study (90 men and 41 women). Some extent of sexual dysfunction was found in 62.2% of men and 51.2% of women. The most frequent sexual dysfunction symptom for both genders was the loss of libido (45%). Hyperprolactinemia was present in 56% of men and 61% of women. The presence of sexual dysfunction was associated with higher doses of antipsychotics, hyperprolactinemia, and smoking in men and with smoking and hyperprolactinemia in postmenopausal women. This study provides real-life evidence of sexual dysfunction and hyperprolactinemia in persons treated with long-acting injectable antipsychotics segregated by gender. The high rates of sexual dysfunction and hyperprolactinemia detected corroborate the need to consider these aspects in clinical practice.
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Jannini TB, Sansone A, Rossi R, Di Lorenzo G, Toscano M, Siracusano A, Jannini EA. Pharmacological strategies for sexual recovery in men undergoing antipsychotic treatment. Expert Opin Pharmacother 2022; 23:1065-1080. [PMID: 35470768 DOI: 10.1080/14656566.2022.2071124] [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] [Indexed: 12/24/2022]
Abstract
INTRODUCTION : First- and second-generation antipsychotics are highly accountable for causing a plethora of medical side effects, ranging from metabolic imbalances to sexual dysfunction (SD), that frequently undermine patient-doctor relationships. Nevertheless, to date antipsychotics are one of the best treatment options for dealing with numerous either acute or chronic conditions like agitation, suicidality, depression, dementia, and of course psychosis. For these reasons, clinicians need to handle them wisely to preserve patients' sexual health, avoid poor therapeutic adherence and prevent high rates of therapy drop-out. AREAS COVERED : This article reviews the literature on pharmacologic approaches for management strategies in men who are administered with antipsychotics and developed SD. The etiology of antipsychotic-induced SD is also discussed. EXPERT OPINION : Clinicians must consider sexual life as a major health domain. To do so, a first step would be to measure and monitor sexual function by means of psychometric tools. Secondly, primary prevention should be conducted when choosing antipsychotics, i.e., picking sex-sparing compounds like aripiprazole or brexpiprazole. Thirdly, if sexolytic compounds cannot be dismissed, such as first-generation antipsychotics, risperidone, paliperidone, or amisulpride, then aripiprazole 5-20 mg/day adjunctive therapy has proven to be most effective in normalizing prolactin levels and consequently treating antipsychotic-induced SD.
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Affiliation(s)
- Tommaso B Jannini
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Sansone
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Rodolfo Rossi
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Giorgio Di Lorenzo
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.,IRCCS-Fondazione Santa Lucia, Rome, Italy
| | - Massimiliano Toscano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.,Department of Neurology, Fatebenefratelli Hospital, Isola Tiberina, Rome, Italy
| | - Alberto Siracusano
- Chair of Psychiatry, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Emmanuele A Jannini
- Chair of Endocrinology and Medical Sexology (ENDOSEX), Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
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González-Rodríguez A, Monreal JA, Mv MVS. Factors Influencing Adherence to Antipsychotic Medications in Women with Delusional Disorder: A Narrative Review. Curr Pharm Des 2022; 28:1282-1293. [PMID: 35272589 DOI: 10.2174/1381612828666220310151625] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/29/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Adherence to medication regimens is of great importance in psychiatry because drugs sometimes need to be taken for long durations in order to maintain health and function. OBJECTIVE To review influences on adherence to antipsychotic medications, the treatment of choice for delusional disorder (DD), and to focus on adherence in women with DD. METHOD A non-systematic narrative review of papers published since 2000 using PubMed and Google Scholar and focusing on women with DD and medication adherence. RESULTS Several factors have been identified as exerting influence on adherence in women with persistent delusional symptoms who are treated with antipsychotics. Personality features, intensity of delusion, perception of adverse effects, and cognitive impairment are patient factors. Clinical time spent with the patient, clarity of communication and regular drug monitoring are responsibilities of the health provider. Factors that neither patient nor clinician can control are the social determinants of health such as poverty, easy access to healthcare, and cultural variables. CONCLUSIONS There has been little investigation into factors that influence adherence in the target population discussed here -e.g. women with DD. Preliminary results of this literature search indicate that solutions from outside the field of DD may apply to this population. Overall, a solid therapeutic alliance appears to be the best hedge against non-adherence.
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Affiliation(s)
- Alexandre González-Rodríguez
- Department of Mental Health. Mutua Terrassa University Hospital. University of Barcelona. Terrassa, Barcelona, Spain
| | - José Antonio Monreal
- Department of Mental Health. Mutua Terrassa University Hospital. University of Barcelona. Institut de Neurociències. UAB. CIBERSAM, Terrassa, Barcelona, Spain
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11
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Levels of prolactin and testosterone and associated sexual dysfunction and breast abnormalities in men with schizophrenia treated with antipsychotic medications. J Psychiatr Res 2021; 143:50-53. [PMID: 34450525 DOI: 10.1016/j.jpsychires.2021.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 11/20/2022]
Abstract
Sexual dysfunction is one of the most bothersome adverse drug effects seen in men and women taking antipsychotic medications and negatively impacts medication adherence. Antipsychotic medications are associated with hyperprolactinemia, which is known to contribute to sexual and hormonal side effects in men. However, testosterone also plays a key factor in male sexual function and may be affected by abnormal prolactin levels through gonadotropin-releasing hormone inhibition. This study was a pilot study undertaken to assess the prevalence of elevations in prolactin levels, related reductions in testosterone levels, associated symptoms of sexual dysfunction and breast abnormalities in male participants, and related distress to these symptoms in men taking prolactin-elevating antipsychotic medications. The study was conducted as a cross-sectional study. Our results showed a notably high prevalence of sexual side effects in this population, with gynecomastia occurring in 50% and penile-related symptoms in 73%. Additionally, we found elevated prolactin levels in 68% and low testosterone levels in 55% of our participants. This study was limited in its power due to a small sample size of 22 men and the lack of a control group. Still, even in our relatively small sample, we see a trend of hyperprolactinemia being associated with low testosterone and a significant correlation of low testosterone levels with penile-related symptoms. This suggests that testosterone plays a major role in the sexual side effects reported by men taking antipsychotics, although larger studies are needed to further categorize this relationship.
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12
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Wu TH, Lin CH, Goh KK, Chen CYA, Chen CH, Lane HY, Lu ML. The Relationships Between Hyperprolactinemia, Metabolic Disturbance, and Sexual Dysfunction in Patients With Schizophrenia Under Olanzapine Treatment. Front Pharmacol 2021; 12:718800. [PMID: 34421613 PMCID: PMC8374865 DOI: 10.3389/fphar.2021.718800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
The aim of the study was to assess the relationship between prolactin levels and sexual dysfunction in patients with schizophrenia who use olanzapine medication. The potential risk factors of hyperprolactinemia and sexual dysfunction were also investigated. Patients with schizophrenia undergoing olanzapine monotherapy were invited to participate in this cross-sectional study. The Arizona Sexual Experiences Scale (ASEX) and the Positive and Negative Syndrome Scale were used to evaluate subjective sexual dysfunction and psychopathology, respectively. Levels of prolactin and metabolic parameters were also measured. In total, 279 participants with schizophrenia were recruited. The overall incidences of hyperprolactinemia, sexual dysfunction, and metabolic syndrome were 51.6, 53.8, and 43.7%, respectively. Higher ASEX scores, higher insulin levels, female sex, and younger age were associated with hyperprolactinemia. Prolactin level was significantly correlated with ASEX score. Elevated prolactin levels, concomitant antidepressant, increased insulin resistance, longer illness duration, and female sex were associated with sexual dysfunction. Female participants recorded higher levels of sexual dysfunction than their male counterparts did, whereas male participants had comparatively lower prolactin levels and lower rates of spousal partnership. Hyperprolactinemia, metabolic syndrome, and sexual dysfunction are prevalent in patients with schizophrenia treated with olanzapine. Clinicians should maintain awareness of these problems and monitor them regularly with their patients.
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Affiliation(s)
- Tzu-Hua Wu
- Department of Clinical Pharmacy, School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan.,Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chieh-Hsin Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan.,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Kah Kheng Goh
- Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Cynthia Yi-An Chen
- Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Chun-Hsin Chen
- Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Yuan Lane
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.,Department of Psychiatry and Brain Disease Research Center, China Medical University Hospital, Taichung, Taiwan
| | - Mong-Liang Lu
- Psychiatric Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Department of Psychiatry, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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13
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Montejo AL, de Alarcón R, Prieto N, Acosta JM, Buch B, Montejo L. Management Strategies for Antipsychotic-Related Sexual Dysfunction: A Clinical Approach. J Clin Med 2021; 10:jcm10020308. [PMID: 33467621 PMCID: PMC7829881 DOI: 10.3390/jcm10020308] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 12/29/2020] [Accepted: 01/08/2021] [Indexed: 12/14/2022] Open
Abstract
Antipsychotic medication can be often associated with sexual dysfunction (SD). Given its intimate nature, treatment emergent sexual dysfunction (TESD) remains underestimated in clinical practice. However, psychotic patients consider sexual issues as important as first rank psychotic symptoms, and their disenchantment with TESD can lead to important patient distress and treatment drop-out. In this paper, we detail some management strategies for TESD from a clinical perspective, ranging from prevention (carefully choosing an antipsychotic with a low rate of TESD) to possible pharmacological interventions aimed at improving patients' tolerability when TESD is present. The suggested recommendations include the following: prescribing either aripiprazole or another dopaminergic agonist as a first option antipsychotic or switching to it whenever possible. Whenever this is not possible, adjunctive treatment with aripiprazole seems to also be beneficial for reducing TESD. Some antipsychotics, like olanzapine, quetiapine, or ziprasidone, have less impact on sexual function than others, so they are an optimal second choice. Finally, a variety of useful strategies (such as the addition of sildenafil) are also described where the previous ones cannot be applied, although they may not yield as optimal results.
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Affiliation(s)
- Angel L. Montejo
- Psychiatry Service, Clinical Hospital of the University of Salamanca, 37007 Salamanca, Spain;
- Institute of Biomedical Research of Salamanca (IBSAL), Paseo San Vicente SN, 37007 Salamanca, Spain; (J.M.A.); (B.B.)
- Nursing School, University of Salamanca, Av. Donates de Sangre SN, 37007 Salamanca, Spain
- Correspondence: ; Tel.: +34-63-9754-620
| | - Rubén de Alarcón
- Psychiatry Service, Infanta Elena Hospital, Juan Ramon Jiménez Hospital, Ronda Exterior Norte S/N, 21080 Huelva, Spain;
| | - Nieves Prieto
- Psychiatry Service, Clinical Hospital of the University of Salamanca, 37007 Salamanca, Spain;
- Institute of Biomedical Research of Salamanca (IBSAL), Paseo San Vicente SN, 37007 Salamanca, Spain; (J.M.A.); (B.B.)
| | - José Mª Acosta
- Institute of Biomedical Research of Salamanca (IBSAL), Paseo San Vicente SN, 37007 Salamanca, Spain; (J.M.A.); (B.B.)
| | - Bárbara Buch
- Institute of Biomedical Research of Salamanca (IBSAL), Paseo San Vicente SN, 37007 Salamanca, Spain; (J.M.A.); (B.B.)
| | - Laura Montejo
- Barcelona Bipolar and Depressive Disorders Program, Institute of Neurosciences, University of Barcelona, IDIBAPS, CIBERSAM, Hospital Clinic of Barcelona, 08401 Catalonia, Spain;
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14
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Liu D, Liu S, Xiu M, Deng H, Guo H, Liu W, Zhang D, Mao Z, Huang D, Huang D, Miao Q, Qiu L, Zhao NO, Wu HE, Zhang X. Sexual Dysfunction in Chronically Medicated Male Inpatients With Schizophrenia: Prevalence, Risk Factors, Clinical Manifestations, and Response to Sexual Arousal. Front Psychiatry 2021; 12:761598. [PMID: 35095591 PMCID: PMC8795612 DOI: 10.3389/fpsyt.2021.761598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 11/23/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Sexual dysfunction is a common symptom in patients with schizophrenia, especially in chronically medicated patients. However, the relationship between sexual dysfunction and emotional response to sexual arousal in male patients with schizophrenia remains unclear. This study aimed to assess the incidence, risk factors of sexual dysfunction in males, and their clinical correlations to sexual arousal in male patients with schizophrenia in China. METHODS A total of 162 male patients, aged 18-50 years, with schizophrenia were recruited from a psychiatric hospital in Ganzhou. The clinical symptoms were assessed by the Positive and Negative Syndrome Scale (PANSS). The Arizona Sexual Experience Scale was utilized to evaluate sexual dysfunction. Erotic images were selected from International Affective Picture System (IAPS). Sixty-eight out of the 162 subjects completed the erotic pictures reactivity task. RESULTS Overall, 48 (29.6%) patients were measured as having global sexual dysfunction, 72 (44.4%) patients as having strength of sex drive dysfunction, 51 (31.5%) patients as having sexual arousal dysfunction, 55 (34.0%) patients as having penile erection dysfunction, 60 (37.0%) patients as having reached orgasm dysfunction, and 60 (37.0%) patients as having satisfaction with orgasm dysfunction. The sexual dysfunction patients had significantly higher scores on the negative symptoms of the PANSS. The only important predictor of sexual dysfunction was the severity of PANSS negative factor. The sense of pleasure and arousal post viewing erotic images in the sexual dysfunction group were lower compared to the non-sexual dysfunction group. The sense of pleasure and approach motivation were significantly negatively correlated with the severity of sexual dysfunction. CONCLUSIONS This study shows that nearly one-third of young and middle-aged chronically medicated male inpatients with schizophrenia suffer from sexual dysfunction. The negative factor of the PANSS can be regarded as the risk factor of sexual dysfunction. Schizophrenia patients with sexual dysfunction experienced lower pleasure and higher avoidance motivation than non-sexual dysfunction patients when exposed to erotic stimuli.
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Affiliation(s)
- Dianying Liu
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Shaohua Liu
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Meihong Xiu
- Beijing HuiLongGuan Hospital, Peking University HuiLongGuan Clinical Medical School, Beijing, China
| | - Hongdong Deng
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Huiyun Guo
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Wanglin Liu
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Delong Zhang
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Zhongzhen Mao
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Dan Huang
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Donghua Huang
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Qiumei Miao
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Lijuan Qiu
- Ganzhou City Key Laboratory of Mental Health, The Third People's Hospital of Ganzhou City, Ganzhou, China
| | - Ning Olivia Zhao
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Hanjing Emily Wu
- Department of Psychiatry and Behavioral Sciences, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Xiangyang Zhang
- Institute of Psychology, Chinese Academy of Sciences, Beijing, China.,Department of Psychology, University of Chinese Academy of Sciences, Beijing, China
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15
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Monteleone P, Amore M, Cabassi A, Clerici M, Fagiolini A, Girardi P, Jannini EA, Maina G, Rossi A, Vita A, Siracusano A. Attitudes of Italian Psychiatrists Toward the Evaluation of Physical Comorbidities and Sexual Dysfunction in Patients With Schizophrenia. Implications for Clinical Practice. Front Psychiatry 2019; 10:842. [PMID: 31824349 PMCID: PMC6879649 DOI: 10.3389/fpsyt.2019.00842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/23/2019] [Indexed: 12/11/2022] Open
Abstract
Treatment guidelines for patients with schizophrenia recommend evaluating their risk of physical comorbidities, especially since these patients are known to have decreased life expectancy due to comorbidities. Therefore, to the authors' knowledge, this is the first national survey conducted to investigate how Italian psychiatrists deal with the risk of physical comorbidities and sexual dysfunction in patients with schizophrenia. A sample of 750 psychiatrists completed an ad hoc online survey investigating their decision making about performing blood tests, clinical and instrumental examinations, and scheduling follow-up appointments in relation to the different phases of the illness and possible pharmacological side effects. Compared to patients in therapeutic continuation, those diagnosed for the first time and those who received a therapeutic change were visited more frequently (every 15 to 17 days vs. every 40 days, respectively), and were more regularly prescribed blood tests and instrumental examinations (every 4.2 to 4.4 months vs. every 9 months, respectively). There was a high interest in the surveillance of cardiometabolic risk. In 54% of patients, prolactin testing was not requested before starting an antipsychotic. In terms of specialist referrals, only 5% of surveyed psychiatrists "never" sought for additional counseling. There was little attention given to sexual functioning assessment based on the survey results about patients' daily life and with regard to deciding to prescribe additional examinations. In fact, only up to 3% of psychiatrists reported assessing sexual functioning using specific psychometric tests. In summary, Italian psychiatrists describes themselves as careful healthcare providers for the physical illnesses of patients with schizophrenia but with several shortcomings. For instance, clinical attention toward patients' sexual and reproductive healthcare needs remains a challenge. Psychiatrists should take the lead for the integrated education, assessment, and care of medical needs of their patients with mental illness. Based on the results of this survey, the authors also believe that a future challenge for the management of patients with mental illness will be the classification of patients based on their risk of comorbidities, to help ensure optimal healthcare provision for those at greater risk of other illnesses.
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Affiliation(s)
- Palmiero Monteleone
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", University of Salerno, Salerno, Italy
| | - Mario Amore
- Section of Psychiatry, Department of Neuroscience, Ophthalmology, Genetics, and Infant-Maternal Science, IRCCS Ospedale Policlinico San Martino, University of Genoa, Genoa, Italy
| | - Aderville Cabassi
- Department of Clinical and Experimental Medicine, Centro Studio dell'Ipertensione Arteriosa e delle Malattie Cardiorenali, Clinica e Terapia Medica, University of Parma, Parma, Italy
| | - Massimo Clerici
- Department of Medicine and Surgery, University of Milano Bicocca, Milan, Italy
| | - Andrea Fagiolini
- Department of Molecular Medicine, University of Siena, Siena, Italy
| | - Paolo Girardi
- Department NESMOS, Sapienza University of Rome, Rome, Italy
| | | | - Giuseppe Maina
- Rita Levi Montalcini Department of Neuroscienze, San Luigi Gonzaga University Hospital, University of Turin, Turin, Italy
| | - Alessandro Rossi
- Department of Mental Health, University of L'Aquila, L'Aquila, Italy
| | - Antonio Vita
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alberto Siracusano
- Department of Medicine Systems, University of Rome Tor Vergata, Rome, Italy
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