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IntroductionAmong the elderly, the availability of tool assessing psychosomatic syndromes is limited. The present study aims at testing inter-rater reliability and concurrent validity of the semi-structured interview for the Diagnostic Criteria for Psychosomatic Research (DCPR-R-SSI) in the elderly of the general population. MethodOne hundred eight subjects were recruited. Participants received a clinical assessment which included the DCPR-R-SSI, the Illness Attitude Scale (IAS), the Geriatric Depression Scale (GDS), the Psychosocial Index (PSI), the Toronto Alexithymia Scale-20 (TAS-20). Analyses of inter-rater reliability of DCPR-R-SSI and concurrent validity between DCPR-R-SSI and self-administered questionnaires were conducted. ResultsDCPR-R-SSI showed excellent inter-rater reliability with a percent of agreement of 90.7% (K Cohen: 0.856 [SE = 0.043], 95% CI: 0.77-0.94). DCPR-R demoralization showed fair concurrent validity with GDS; concurrent validity was also fair between DCPR-R Alexithymia and TAS-20, and between DCPR-R allostatic overload and PSI allostatic load, while the concurrent validity between DCPR-R Disease Phobia and IAS was moderate. ConclusionDCPR-R-SSI represents a reliable and valid tool to assess psychosomatic syndromes in the elderly. DCPR-R is in need of being implemented in the elderly clinical evaluation.

Individual attitudes and behavior related to health and disease are major components of clinical encounters. These factors shape lifestyle, presentation of symptoms, access to patient care, interactions between patients and physicians, adherence to medical advice, and response to treatment. Health attitudes and behavior may range from anxiety and worry about illness to various forms of denial, such as delay of seeking care and lack of adherence to treatment. When attitudes result in health-damaging behavior, they may be particularly difficult to understand and become a source of frustration to both physicians and patients. Devising appropriate responses by health care providers may contribute to improving final outcomes and decrease health care costs. In particular, health behavior is likely to play a major role in the process of convalescence, in self-management of chronic conditions, in determining a state of recovery, and whenever a rehabilitation process is involved. Understanding the spectrum of health attitudes and behavior is also crucial for motivating people to make beneficial changes (lifestyle medicine), as well as for implementing safety procedures in the community.

INTRODUCTION: According to the revised version of the Diagnostic Criteria for Psychosomatic Research (DCPR-R), this study explored the prevalence and clinical correlates of DCPR-R psychosomatic syndromes in the elderly and tested whether DCPR-R provide an incremental contribution to the prediction of psychosocial functioning over and above DSM-5.METHOD: One hundred seven elderly subjects were recruited. Participants received a clinical assessment, which included the DCPR-Revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5-Clinician Version (SCID-5-CV), the Psychological Well-Being (PWB) Scales, the Geriatric Anxiety Scale (GAS) and the Geriatric Depression Scale (GDS). Analyses of covariance (ANCOVA) and hierarchical regression analyses were run.RESULTS: Twenty-two (20.6%) subjects had at least one DSM-5 diagnosis, and 62 (57.9%) reported at least one DCPR-R diagnosis. Subjects with at least one DCPR-R diagnosis showed lower PWB Personal Growth and PWB Purpose in Life than those without DCPR-R diagnoses. When the incremental validity of the DCPR-R was tested using PWB Personal Growth, PWB Purpose in Life, PWB Self-acceptance, GAS Cognitive symptoms and GAS affective symptoms subscales as criterion variable, the DCPR-R increased up to 0.135-0.263 the explained variance.CONCLUSION: The DCPR-R might be implemented together with the DSM-5 to have a comprehensive assessment of elderly subjects.

BackgroundMental pain has been proposed as a global person-centered outcome measure. The aim of this cross-sectional study was to test an essential requisite of such a measure, namely that mental pain incorporates independent contributions from a range of discrete but disparate outcome measures.MethodsTwo hundred migraine patients were assessed concerning migraine disability, psychosomatic syndromes, mental pain, depression, anxiety, and psychosocial dimensions. General linear models were tested to verify which measures would individually make unique contributions to overall mental pain.ResultsThe final model, accounting for 44% of variance, identified that higher mental pain was associated with more severe depressive symptoms, higher migraine disability, lower well-being, and poorer quality of life.ConclusionIn this sample, mental pain was shown to behave as expected of a global outcome measure, since multiple measures of symptomatology and quality of life showed modest but significant bivariate correlations with mental pain and some of these measures individually made unique contributions to overall mental pain.

BACKGROUND: The assessment of psychological well-being and euthymia represents an emerging issue in clinical psychology and psychiatry. Rating scales and indices such as the 5-item version of the World Health Organization Well-Being Index (WHO-5) and the Euthymia Scale (ES) were developed but insufficient attention has been devoted to the evaluation of their cross-cultural validity. This is the first study using Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria to assess cross-cultural validity and sensitivity of five different versions of the WHO-5 and ES.METHODS: A multicenter cross-sectional study involving a total of 3762 adult participants from different European (i.e., Italy, Poland, Denmark) and non-European (i.e., China, Japan) countries was conducted. Item Response Theory models (Mokken and Rasch analyses) were applied.RESULTS: Mokken coefficients of scalability were found to range from 0.42 to 0.84. The majority of the versions of the WHO-5 fitted the Rasch model expectations. Paired t-tests revealed that the Italian and Danish WHO-5 versions were unidimensional. Person Separation Reliability indices showed that the Polish, Danish, and Japanese ES versions could reliably discriminate between subjects with different levels of euthymia.LIMITATIONS: A convenience sampling was used, thus limiting the generalizability of study findings. In addition, no measures of negative mental health were administered.CONCLUSIONS: WHO-5 can be used in international studies for cross-cultural comparisons since it covers transcultural components of subjective well-being. Findings also suggest that the ES can be used as a cross-cultural screening tool since it entailed the clinimetric property of sensitivity.

Introduction: The corona pandemic has been a life event causing negative consequences on mental health. Mental health consists of positive and negative dimensions. The present longitudinal study investigated how positive and negative dimensions changed over 15 months after the Covid-19 outbreak. Potential changes of excessive social media use (SMU) and its relationship with mental health were also investigated. Method: Data (N = 189) on distress (measured overall and as depression, anxiety, and stress), well-being and excessive SMU were collected at three time points (baseline, BL; 3-month follow-up, FU1; 15-month follow-up, FU2) via online surveys in Italy. Repeated analyses of variance were used to test differences among the three measurement time points. Mediational models were applied. Results: Distress did not change over time, well-being decreased and excessive SMU increased significantly. The relationship between distress at BL and excessive SMU at FU2 was significant (total effect, c: p

Demoralization is a complex clinical phenomenon which has raised a growing interest in clinical and research realms. The present systematic review of the literature aimed at (1) updating on demoralization prevalence in different populations, (2) identifying the instruments more largely used to assess demoralization, and (3) verifying whether new tools of assessment have been proposed. PubMed and Web of Science were searched from inception to April 2022. Search terms were: demoralization/demoralized/demoralizing/demoralised/demoralising. PRISMA guidelines were followed. GRADE rating system was used. A total of 188 papers were included. Demoralization appeared to be a distinctive psychological state common in medical, psychiatric, and non-clinical settings, thus not limited to life-threatening diseases. Diagnostic Criteria for Psychosomatic Research (DCPR) and Demoralization Scale (DS) are the most commonly used tools to assess it. DCPR allow to diagnose demoralization as a manifestation of dealing with chronic stress. DS captures dimensionally a psychological distress related to end of life. Demoralization is associated with clinical features encompassing allostatic overload, quality of life, wellbeing/euthymia. Implications on health outcomes and treatment are discussed. Demoralization warrants careful consideration in clinical contexts through valid assessment procedures. DCPR are recommended to diagnose it, DS can be helpful to capture clinical details.

BACKGROUND: A set of enduring conditions have been reported in the literature involving persistent sexual dysfunction after discontinuation of serotonin reuptake inhibiting antidepressants, 5 alpha-reductase inhibitors and isotretinoin.OBJECTIVE: To develop diagnostic criteria for post-SSRI sexual dysfunction (PSSD), persistent genital arousal disorder (PGAD) following serotonin reuptake inhibitors, post-finasteride syndrome (PFS) and post-retinoid sexual dysfunction (PRSD).METHODS: The original draft was designed using data from two published case series (Hogan et al., 2014 and Healy et al., 2018), which represent the largest public collections of data on these enduring conditions. It was further developed with the involvement of a multidisciplinary panel of experts.RESULTS: A set of criteria were agreed upon for each of the above conditions. Features of PSSD, PFS and PRSD commonly include decreased genital and orgasmic sensation, decreased sexual desire and erectile dysfunction. Ancillary non-sexual symptoms vary depending on the specific condition but can include emotional blunting and cognitive impairment. PGAD presents with an almost mirror image of unwanted sensations of genital arousal or irritability in the absence of sexual desire. A new term, post-SSRI asexuality, is introduced to describe a dampening of sexual interest and pleasure resulting from a pre-natal or pre-teen exposure to a serotonin reuptake inhibitor.CONCLUSIONS: These criteria will help in both clinical and research settings. As with all criteria, they will likely need modification in the light of developments.

Objective: This is the first study applying Clinimetric Patient-Reported Outcome Measures (CLIPROM) criteria to evaluate the construct validity, sensitivity, and clinical utility of the SCL-90-R in patients with Parkinson’s disease (PD). Methods: A Rasch analysis was conducted using a sample of 488 PD outpatients. Results: Testing for dimensionality revealed that less than 5% of t-tests were significant, indicating that the SCL-90-R subscales entailed the property of construct validity. As to the total score, a Person Separation Reliability Index of .96 was found. Conclusions: The SCL-90-R total score is a sensitive screening measure that can be used not only to differentiate healthy stress reactions from symptoms of psychological distress but also to detect PD patients with an increased risk for psychiatric complications. As to the subscales, the brief versions that did not include misfitting items should be used to assess the severity of specific symptoms of psychological distress affecting PD patients.

Treatment of depression with antidepressants is partly effective. Transcranial alternating current stimulation can provide a non-pharmacological alternative for adult patients with major depressive disorder. However, no study has used the stimulation to treat first-episode and drug-naïve patients with major depressive disorder. We used a randomized, double-blind, sham-controlled design to examine the clinical efficacy and safety of the stimulation in treating first-episode drug-naïve patients in a Chinese Han population. From 4 June 2018 to 30 December 2019, 100 patients were recruited and randomly assigned to receive 20 daily 40-min, 77.5 Hz, 15 mA, one forehead and two mastoid sessions of active or sham stimulation (n = 50 for each group) in four consecutive weeks (Week 4), and were followed for additional 4-week efficacy/safety assessment without stimulation (Week 8). The primary outcome was a remission rate defined as the 17-item Hamilton Depression Rating Scale (HDRS-17) score ≤ 7 at Week 8. Secondary analyses were response rates (defined as a reduction of ≥ 50% in the HDRS-17), changes in depressive symptoms and severity from baseline to Week 4 and Week 8, and rates of adverse events. Data were analysed in an intention-to-treat sample. Forty-nine in the active and 46 in the sham completed the study. Twenty-seven of 50 (54%) in the active treatment group and 9 of 50 (18%) in the sham group achieved remission at the end of Week 8. The remission rate was significantly higher in the active group compared to that in the sham group with a risk ratio of 1.78 (95% confidence interval, 1.29, 2.47). Compared with the sham, the active group had a significantly higher remission rate at Week 4, response rates at Weeks 4 and 8, and a larger reduction in depressive symptoms from baseline to Weeks 4 and 8. Adverse events were similar between the groups. In conclusion, the stimulation on the frontal cortex and two mastoids significantly improved symptoms in first-episode drug-naïve patients with major depressive disorder and may be considered as a non-pharmacological intervention for them in an outpatient setting.

BACKGROUND: Euthymia has been described as a transdiagnostic construct characterized by the absence of mood disturbances and the presence of an integration of psychic forces, such as coping strategy and well-being. A multidimensional measure, the Euthymia Scale (ES), has been proposed to assess it. We investigated construct and concurrent validity of the ES.METHODS: Construct validity was studied via Rasch and Mokken analyses and compared with that of the 11-item Resilience Scale (RS-11) and 9-item Positive Mental Health Scale (PMH-Scale). A total of 951 participants were recruited (77.5% women; 24.86 ± 5.62 years).RESULTS: The ES, RS and PMH demonstrated similar sensitivity and construct validity. Findings indicate minor needs for adjustments only. As expected the ES demonstrated a strong negative correlation with neuroticism.LIMITATIONS: The convenience sample of subjects recruited primarily from female Italian university students and a community-based data collection limit the generalizability of the present findings. The cross-sectional design precludes the assessment of test-retest reliability, predictive and incremental validity. Only self-report measures and a Likert version of the ES were used.CONCLUSIONS: ES is the most comprehensive measure of euthymia. The RS-11 is a valid measure of a specific component of euthymia, namely subjective ability to cope with stress and empower well-being in face of life adversities. The PMH-Scale is a valid measure of overall positive mental health.

The family climate has notable impact on cognitive, emotional, behavioural, social and physical development of children and adolescents and can be influenced by parents' health status. The present study aimed at evaluating whether living with a parent with alcohol use disorder negatively influences the perceived emotional family climate, parental attitudes and internal representations of family relationships. Forty-five children living with a parent with alcohol use disorder and 45 controls, matched for sex and age, completed the Level of Expressed Emotion Scale and the Family Attitudes Questionnaire. Their significant parent completed the Parental Attitudes Scale. The results suggested that living with a parent with an alcohol use disorder increased the risk of having perceived higher levels of emotional response, attitude towards illness and expectations from their parents; it also increased the probability of being exposed to lower parental pleasure and of having represented worse family relationships. Emotion regulation interventions might be useful to protect children living with a parent with alcohol use disorder from a potential chaotic and unpredictable family environment.

Depression in chronic migraine is a common and vexing problem. Stress-oriented psychotherapies showed to improve depressive symptoms but not to affect migraine disability or attacks. Well-Being Therapy (WBT) is a short-term psychotherapy intervention based on promoting well-being and optimizing functioning, which showed to be effective in the treatment of residual depressive symptoms and chronic pain. This single case describes an account of successful WBT for a case of chronic migraine with depressive symptoms. The patient is a 37-year old employed, engaged, Caucasian heterosexual woman who had chronic migraine without aura and depressive symptoms and received eight WBT sessions. Number of migraine attacks, migraine disability, and psychological variables were assessed at baseline, at sessions 4 and 8 of WBT, and at 3-month follow-up. At session 8 of WBT, a decrease in number of migraine attacks and migraine disability was observed together with an improvement on depressive symptoms as well as an increase of well-being and euthymia. The positive effects of WBT were maintained at 3-month follow-up. WBT may be a promising intervention for chronic migraine patients with depressive symptoms.

Staging has been increasingly used in unipolar depression since its introduction in the nineties. Several models are available, but their differential features and implications are not completely clear. We systematically reviewed: (a) staging models of longitudinal development of unipolar depression; (b) staging models of treatment-resistant unipolar depression; (c) their applications. MEDLINE, PsycINFO, EMBASE, and Web of Science were examined according to PRISMA guidelines from inception to December 2021. Search terms were: ‘stage/staging’, combined using the Boolean ‘AND’ operator with ‘psychiatric disorder/mental disorder/depressive/mood disorder’. A total of 169 studies were identified for inclusion: 18 described staging models or applications, 151 described treatment-resistant staging models or applications. Staging models of longitudinal development were found to play a key role in formulating sequential treatment, with particular reference to the use of psychotherapy after pharmacotherapy. Staging methods based on treatment resistance played a crucial role in setting entry criteria for randomized clinical trials and neurobiological investigations. Staging is part of clinimetrics, the science of clinical measurements, and its role can be enhanced by its association with other clinimetric strategies, such as repeated assessments, organization of problematic areas, and evaluation of phenomena that may affect responsiveness. In research, it may allow to identify more homogeneous populations in terms of treatment history that may diminish the likelihood of spurious results in comparisons. In clinical practice, the use of staging in a clinimetric perspective allows clinicians to make full use of the information that is available for an individual patient at a specific time.

Background A number of patient-reported outcomes (PROs) have been developed but insufficient attention has been devoted to the assessment of their clinimetric properties. Clinimetrics, the science of clinical measurements, has been considered an emerging approach for evaluating reliability and validity of PROs. This is the first study using clinimetric principles to compare the construct and criterion validity of the Major Depression Inventory (MDI), the Beck Depression Inventory-II (BDI-II), the World Health Organization Well-Being Index (WHO-5), three of the most widely used PROs for the assessment of depression. Methods Construct validity was evaluated via Item Response Theory (IRT) models (i.e., combining Rasch and Mokken analyses). Using the ICD-10 diagnostic algorithm for any depression as the gold standard, Receiver Operating Characteristic (ROC) curves were performed to examine the criterion validity of PROs. Results One hundred healthy subjects (73% females, 32.6 ± 10.5 years) participated in the study, giving a response rate of 90.1%. When using IRT analyses, MDI and WHO-5 were found to be reliable and unidimensional, while BDI-II showed lack of unidimensionality. ROC analyses supported the diagnostic accuracy of MDI and the screening properties of WHO-5. Limitations The main limitations of the present study are that healthy subjects were assessed only via only self-reported measures and a cross-sectional design was used. Conclusions WHO-5 and MDI outperformed BDI-II in terms of construct and criterion validity. WHO-5 should be considered when screening for depression, while MDI should be used as a valid diagnostic instrument and as a unidimensional measure to assess depression severity.

Introduction: A clear picture of neonatal withdrawal signs due to in utero selective serotonin reuptake inhibitor (SSRI) exposure and its consequences is still missing. Objective: A systematic review and a meta-analysis were performed to provide an overview of neonatal withdrawal signs following late in utero exposure to SSRIs and to quantify the corresponding risks. Methods: MEDLINE, Web of Science, and Embase were searched from inception to January 2021. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed. English-language observational studies reporting on acute postpartum outcomes following late in utero exposure to SSRIs or SSRIs/venlafaxine were evaluated. Results: Of 2,269 citations reviewed, 79 studies were assessed for eligibility; 13 were included in the qualitative analysis of the literature, which allowed us to identify 26 signs. A meta-analysis was run separately for studies on SSRI exposure (n = 3) and those on SSRI/venlafaxine exposure (n = 6). Hypoglycemia was identified as a withdrawal sign based on the SSRI studies. Tremors, hypotonia, tachycardia, rapid breathing, respiratory distress, and hypertonia were identified as withdrawal signs based on the SSRI/venlafaxine studies. Conclusions: The present work provides a framework for the identification of neonatal SSRI withdrawal syndrome. Tapering and discontinuation of antidepressant drugs before and during the early phase of pregnancy are worth attempting to prevent the occurrence of this syndrome.

BACKGROUND: Post-SSRI Sexual Dysfunction (PSSD) is characterized by sexual and emotional symptoms associated to the exposure to Selective Serotonin Reuptake Inhibitors (SSRI) or Serotonin Noradrenaline Reuptake Inhibitors (SNRI). OBJECTIVE: The present study provides a comprehensive picture on demographic and clinical characteristics associated to PSSD. METHODS: An online survey was run on subjects self-declaring as affected by PSSD. The survey collected socio-demographic and clinical data via questions created ad hoc and three standardized scales (Arizona Sexual Experiences Scale, Hospital Anxiety and Depression Scale, World Health Organization Wellbeing Index). RESULTS: A total of 135 subjects (115 males; mean age 31.9 ± 8.9 years) was analysed. The syndrome was more represented among young, heterosexual males after the exposure to SSRI/SNRI at relatively high doses. The major findings involved the temporal sequence of symptoms: 118 subjects had symptoms both during and after SSRI/SNRI administration, and 17 only after, thus deposing for a iatrogenic action of SSRI/SNRI. Different variables, represented by both emotional and sexual symptoms, accounted for the variability of the severity of the sexual dysfunction as well as of wellbeing. CONCLUSIONS: Based on the present results, PSSD is a complex iatrogenic syndrome in need of being further studied and understood.

Background: As the fight against the COVID-19 epidemic continues, medical workers may have allostatic load. Objective: During the reopening of society, medical and nonmedical workers were compared in terms of allostatic load. Methods: An online study was performed; 3,590 Chinese subjects were analyzed. Socio-demographic variables, allostatic load, stress, abnormal illness behavior, global well-being, mental status, and social support were assessed. Results: There was no difference in allostatic load in medical workers compared to nonmedical workers (15.8 vs. 17.8%; p = 0.22). Multivariate conditional logistic regression revealed that anxiety (OR = 1.24; 95% CI 1.18–1.31; p < 0.01), depression (OR = 1.23; 95% CI 1.17–1.29; p < 0.01), somatization (OR = 1.20; 95% CI 1.14–1.25; p < 0.01), hostility (OR = 1.24; 95% CI 1.18–1.30; p < 0.01), and abnormal illness behavior (OR = 1.49; 95% CI 1.34–1.66; p < 0.01) were positively associated with allostatic load, while objective support (OR = 0.84; 95% CI 0.78–0.89; p < 0.01), subjective support (OR = 0.84; 95% CI 0.80–0.88; p < 0.01), utilization of support (OR = 0.80; 95% CI 0.72–0.88; p < 0.01), social support (OR = 0.90; 95% CI 0.87–0.93; p < 0.01), and global well-being (OR = 0.30; 95% CI 0.22–0.41; p < 0.01) were negatively associated. Conclusions: In the post-COVID-19 epidemic time, medical and nonmedical workers had similar allostatic load. Psychological distress and abnormal illness behavior were risk factors for it, while social support could relieve it.

Reducing the risk of relapses is a critical component of major depressive disorders treatment. Guidelines suggest maintenance with antidepressant drugs in recurrent depression, but this solution has recently been questioned.The aim of this article is to provide a critical review of the literature of the main treatment options currently available to prevent relapse and recurrence in depression.We compared long-term antidepressant therapy (i.e., indefinite maintenance of antidepressant), intermittent antidepressant therapy (i.e., use of antidepressants mainly limited to the acute phases), use of psychotherapy in the sequential model (i.e., pharmacotherapy in the acute phase and psychotherapy in the residual phase).We argue that the same solution may not apply to all patients and question the feasibility of a single course of treatment in the setting of complex disorders that are encountered in practice. The clinician should weigh advantages and disadvantages in the individual case.The sequential model appears to be particularly indicated in recurrent depression. KEY POINTS Relapse is a major challenge of depressive disorders treatment Treatment options currently available include long-term antidepressants, intermittent antidepressants, addition of psychotherapy to pharmacotherapy in the sequential model Maintenance with antidepressants in recurrent depression has recently been questioned The sequential model appears to be particularly indicated in recurrent depression.

Background Withdrawal syndromes can occur after dose reduction or discontinuation of selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs). Few measurement instruments are available to assess them: Diagnostic Clinical Interview for Drug Withdrawal 1-New Symptoms of SSRI and SNRI (DID-W1) and Discontinuation Emergent Signs and Symptoms (DESS) checklist. We assessed their interrater reliability, verified the percent agreement between the two, and tested DESS sensitivity and specificity on the basis of the diagnoses formulated via the DID-W1. Methods One-hundred thirty-four subjects who referred for withdrawal at 3 outpatient facilities were enrolled and assessed via the DESS and the DID-W1. Percent agreement and Cohen kappa were calculated to measure DID-W1 and DESS interrater reliability, as well as the agreement between DID-W1 and DESS items. Sensitivity and specificity of DESS were derived from the identification of true-positive, false-negative, true-negative, and false-positive on the DID-W1. Results Both tools showed excellent interrater reliability (DID-W1 Cohen kappa = 0.958; DESS Cohen kappa = 0.81-1). The degree of agreement between DID-W1 and DESS items was poor or fair (Cohen kappa < 0.40) for some items and moderate (Cohen kappa = 0.41-0.60) for others. Sensitivity and specificity of DESS were 0.937 (true-positive = 60, false-negative = 4) and 0.285 (true-negative = 20, false-positive = 50), respectively. Conclusions DID-W1 was a reliable method to identify and diagnose withdrawal syndromes. The DESS checklist showed to be a useful tool for detecting withdrawal SSRI/SNRI symptoms when the aim is to achieve high sensitivity to identify true positives.

Introduction Most people who seek treatment for depression experience relapse or recurrence, thus prevention represents a very important way to reduce suffering and burdens associated with this illness. Areas covered Preventive psychological interventions after depression remission include maintenance psychotherapy after an initial course of psychological treatment and the sequential model, i.e. the use of psychotherapy after pharmacotherapy or the application of drug treatment after a course of psychotherapy. Maintenance psychotherapy is aimed to prolong the effects obtained in the previous treatment course. The sequential model appeared to be more effective than monotherapy or the simultaneous combination of two different interventions. Expert opinion The patient should be informed about the prognosis of depressive illness and treatment options. One option would be to continue with an antidepressant drug indefinitely; however, loss of clinical effect may occur. The other option would be to start working on the prevention of the next episode. Thus, a sequential approach might be proposed. It includes antidepressants in the acute phase and a short-term course of cognitive-behavioral therapy in the residual phase. This approach has been specifically applied for its preventive effects. Completing the psychotherapy course with sessions of Well-Being Therapy would be optimal to enhance psychological well-being and euthymia.

Objective.The Diagnostic Criteria for Psychosomatic Research (DCPR) are those of psychosomatic syndromes that did not find room in the classical taxonomy. More recently, the DCPR were updated, called DCPR-revised (DCPR-R). The present study was conducted to test the criterion-related validity of the DCPR-R.Methods.Two hundred consecutive subjects were enrolled at the Headache Center of Careggi University Hospital (Italy): 100 subjects had a diagnosis of chronic migraine (CM) and 100 had a diagnosis of episodic migraine (EM). Participants received a clinical assessment, which included the DCPR-revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5 (SCID-5), and the psychosocial index (PSI).Results.Forty-seven subjects (23.5%) had at least one DSM-5 diagnosis: major depressive disorder (8.5%; n = 17) and agoraphobia (7.5%; n = 15) were the most frequent. One hundred and ten subjects (55%) reported a DCPR-R diagnosis: allostatic overload (29%; n = 58) and type A behavior (10.5%; n = 21) were the most frequent. When the incremental validity of the DCPR system over the DSM system was tested using PSI subscales as the criterion variable, the DCPR-R increased up to 0.11–0.24 the amount of explained variance. Subjects with at least one DCPR-R diagnosis showed lower PSI well-being scores (p = .001), higher PSI stress scores (p < .001), and higher PSI psychological distress scores (p = .008) than subjects without a DCPR-R diagnosis.Conclusion. The DCPR-R showed a good criterion-related validity in migraine outpatients. Thus, they might be implemented, together with the DSM-5, in the assessment of migraine subjects.

Studies on psychotropic medications decrease, discontinuation, or switch have uncovered withdrawal syndromes. The present overview aimed at analyzing the literature to illustrate withdrawal after decrease, discontinuation, or switch of psychotropic medications based on the drug class (i.e., benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonists, antidepressants, ketamine, antipsychotics, lithium, mood stabilizers) according to the diagnostic criteria of Chouinard and Chouinard [Psychother Psychosom. 2015;84(2):63–71], which encompass new withdrawal symptoms, rebound symptoms, and persistent post-withdrawal disorders. All these drugs may induce withdrawal syndromes and rebound upon discontinuation, even with slow tapering. However, only selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, and antipsychotics were consistently also associated with persistent post-withdrawal disorders and potential high severity of symptoms, including alterations of clinical course, whereas the distress associated with benzodiazepines discontinuation appears to be short-lived. As a result, the common belief that benzodiazepines should be substituted by medications that cause less dependence such as antidepressants and antipsychotics runs counter the available literature. Ketamine, and probably its derivatives, may be classified as at high risk for dependence and addiction. Because of the lag phase that has taken place between the introduction of a drug into the market and the description of withdrawal symptoms, caution is needed with the use of newer antidepressants and antipsychotics. Within medication classes, alprazolam, lorazepam, triazolam, paroxetine, venlafaxine, fluphenazine, perphenazine, clozapine, and quetiapine are more likely to induce withdrawal. The likelihood of withdrawal manifestations that may be severe and persistent should thus be taken into account in clinical practice and also in children and adolescents.

Background:Benzodiazepines (BZs) and selective serotonin reuptake inhibitors (SSRIs) are effective in the pharmacologic treatment of panic disorder (PD). However, treatment guidelines favor SSRIs over BZs based on the belief that BZs are associated with more adverse effects than SSRIs. This belief, however, is currently supported only by opinion and anecdotes.Aim:The aim of this review and meta-analysis was to determine if there truly is evidence that BZs cause more adverse effects than SSRIs in acute PD treatment.Methods:We systematically searched Web of Science, PubMed, Cochrane Central Register of Controlled Trials, and clinical trials register databases. Short randomized clinical trials of a minimum of four weeks and a maximum of 12 weeks that studied SSRIs or BZs compared to placebo in acute PD treatment were included in a meta-analysis. The primary outcome was all-cause adverse event rate in participants who received SSRIs, BZs, or placebo.Results:Overall, the meta-analysis showed that SSRIs cause more adverse events than BZs in short-term PD treatment. Specifically, SSRI treatment was a risk factor for diaphoresis, fatigue, nausea, diarrhea, and insomnia, whereas BZ treatment was a risk factor for memory problems, constipation, and dry mouth. Both classes of drugs were associated with somnolence. SSRIs were associated with abnormal ejaculation, while BZs were associated with libido reduction. BZs were protective against tachycardia, diaphoresis, fatigue, and insomnia.Conclusion:Randomized, blinded studies comparing SSRIs and BZs for the short-term treatment of PD should be performed. Clinical guidelines based on incontrovertible evidence are needed.

BackgroundPain has been qualified under four categories: nociception, perception of pain, suffering, and pain behaviors. Most of the literature on migraine has devoted attention to the first two. The aim of the present cohort study was to investigate patients with migraine enrolled at a tertiary care unit to study suffering and mental pain and identify potential risk factors for migraine.MethodsAn observational cross-sectional study was carried out on patients with chronic migraine (CM) and episodic migraine (EM), and healthy subjects (HS). The three groups were matched for age and sex. A comprehensive assessment of migraine disability, pain, psychiatric disorders, psychosomatic syndromes, depressive and anxious symptoms, euthymia, psychosocial variables, mental pain, and pain-proneness (PP) was performed.ResultsThree hundred subjects were enrolled (100 CM, 100 EM, and 100 HS). Based on the multiple regression analyses, those presenting PP (social impairment: odds ratio [OR] = 3.59, 95% confidence interval [CI] = 1.14-11.29; depressive symptoms: OR = 3.82, 95% CI = 1.74-8.41) were more likely to be CM than HS. Those with higher levels of PP (social impairment: OR = 4.04, 95% CI = 1.60-10.22; depressive symptoms: OR = 2.02, 95% CI = 1.26-3.24) were more likely to be EM than HS. Those presenting higher levels of mental pain were more likely to be CM than EM (OR = 1.45, 95% CI = 1.02-2.07).ConclusionMigraine is an unpleasant sensory and emotional experience associated with psychosocial manifestations that might contribute to the level of suffering of the individuals. Mental pain resulted to be the variable that most differentiated patients with CM from EM.

Depressive and anxiety disorders are frequently associated. Depression may be a complication of anxiety and anxiety can complicate depression. The nature of their relationship has been a source of controversy. Reviews generally base their conclusions on randomized controlled trials and meta-analyses that refer to the average patient and often clash with the variety of clinical presentations that may occur when anxiety and depression coexist. The aim of this review was to examine the literature according to profiling of subgroups of patients based on clinimetric criteria, in line with the recently developed concept of medicine-based evidence. We critically reviewed the literature pertaining to the specific presentations of anxiety and depression, outlining the advantages and disadvantages of each treatment approach. The following prototypic cases were presented: depression secondary to an active anxiety disorder, depression in patients with anxiety disorders under treatment, anxious depression, anxiety as a residual component of depression, and demoralization secondary to anxiety disorder. We argue that the selection of treatment when anxiety and depression coexist should take into account the modalities of presentation and be filtered by clinical judgment. Very different indications may ensue when the literature is examined according to this perspective.

Smoking abstinence expectancies are beliefs about negative and positive short-term psychological and physiological consequences of not smoking. The Smoking Abstinence Expectancies Questionnaire (SAEQ) is a widely used Patient-Reported Outcome Measure (PROM) to assess smoking abstinence expectancies. It has four subscales: negative mood, somatic symptoms, harmful consequences, positive consequences. Although studied from a psychometric perspective, the SAEQ needs further evaluation. Clinimetrics, and its Clinimetric Criteria for Patient-Reported Outcome Measures (CLIPROM), offers a robust method to evaluate the SAEQ. We verified construct validity and sensitivity of the Italian version of the SAEQ applying CLIPROM criteria. A total of 293 adult Italian smokers were consecutively enrolled at two smoking cessation clinics and assessed via the SAEQ. Item Response Theory models (i.e., combining Rasch and Mokken analyses) were used to test construct validity and sensitivity. The total score of the SAEQ was not found to be unidimensional but each SAEQ subscale score was. PSI (0.90) indicated that the total score of the SAEQ could reliably discriminate between respondents with different levels of the trait under assessment, whereas SAEQ subscales on negative mood and harmful consequences could reliably distinguish between different groups but not between different subjects (PSI ranging from 0.77 and 0.78). Overall, the total score of the SAEQ is a sensitive screening PROM and can be used at smoking cessation clinics to discriminate between subjects with different levels of smoking abstinence expectancies. SAEQ subscales should be used to detect severity and subjective burden of a wide range of expected effects of nicotine abstinence.

A number of rating scales evaluating symptoms of nicotine withdrawal have been developed over the years but insufficient attention has been devoted to the assessment of their clinimetric properties. Clinimetrics, the science of clinical measurements, is an innovative approach, particularly useful for assessing the validity of rating scales. This is the first study using clinimetric principles to test the construct validity of the Smoker Complaint Scale (SCS), a self-rating scale specifically developed to assess acute symptoms of nicotine withdrawal. Construct validity was evaluated via Item Response Theory (IRT) models (i.e., combining Rasch and Mokken analyses). A total of 366 subjects (mean age = 34.0, SD = 11.3 years) participated in the study. IRT analyses showed that SCS was a multidimensional measure of symptoms of nicotine withdrawal, including unidimensional subscales, particularly a four-item subscale (the SCS4), which was found to entail the clinimetric property of construct validity. IRT analyses also revealed that affective symptoms of nicotine withdrawal preceded cognitive ones. The SCS should be considered as an item bank, including a particularly valid subscale, the SCS4 that can be used as a screening or outcome measure to evaluate the severity of cognitive and affective symptoms of nicotine withdrawal. SCS4 is a sensitive clinimetric index which differentiates “ceiling symptoms” of nicotine withdrawal (e.g., “feeling slowed down”) from “floor symptoms” of nicotine withdrawal (e.g., “feeling lightheaded”) that emerge in the severe form of nicotine withdrawal.

A specific brief psychotherapeutic intervention aimed at empowering psychological well-being, the so-called Well-Being Therapy (WBT), has been manualized in 2016 by Giovanni Fava and has shown to be effective in randomized controlled trials. WBT is based on the multidimensional model of psychological well-being developed by Marie Jahoda which encompasses environmental mastery, personal growth, purpose in life, autonomy, self-acceptance, positive relations with others, and balance of psychic forces. WBT aims at promoting the achievement of an optimal-balanced functioning between the dimensions of psychological well-being, and such a balance is subsumed under the rubric of euthymia. There are evidences that WBT may be a suited clinical approach for second- or third-line treatment of depressive disorders with particular reference to decreasing vulnerability to relapse and modulating psychological well-being and mood. It has been also proposed a role of WBT in depressive disorders in clinical conditions such as treatment resistance, loss of antidepressant clinical efficacy, persistent post-withdrawal disorders, trauma exposure, and medical disease comorbidity. The present chapter provides an overview of the possible applications of WBT as treatment of depressive disorders.