Heart rate variability, serum cortisol levels and temperament in a sample of workers exposed to occupational stress: a preliminary report.

Work-related stress is an emerging risk for psychiatric occupational disorders including Adjustment Disorders (AD). The aim of this study was to investigate in workers exposed to occupational stress suffering from AD about putative indices of stress and mental health resilience such as serum cortisol (seC) levels, Heart Rate Variability (HRV) and affective temperaments. We consecutively recruited 15 male and 15 female AD patients between workers evaluated for occupational stress at an Italian Occupational Medicine Unit. SeC levels were measured by specific immunoassay. HRV indices were recorded using Task Force® Monitor system (CNSystems, Graz, Austria). Specific questionnaires were used to measure perceived and occupational stress, psychopathological symptoms and temperament. Women presented higher levels of occupational stress, higher High-Frequency HRV (HF-HRV) and lower Low-Frequency HRV (LF-HRV) than men. SeC levels were positively correlated with LF-HRV values and negatively with HF-HRV values. The LF/HF ratio resulted to be inversely correlated with the score of Harm Avoidance temperament dimension and directly with the score of Reward Dependence temperament dimension. In conclusion, in AD patients exposed to occupational stress high seC levels and reward dependence appear to be associated with a pattern of HRV reflecting less mental health resilience.

Mental disability management within occupational health surveillance.

INTRODUCTION: The management of workers with mental disability is a current topic of great interest. The aim of the article is to report the experience of managing cases of employees with mental disabilities in an Italian university hospital and to describe the preventive measures adopted and the therapeutic programs carried out. METHODS: A group of 100 workers suffering from psychiatric disorders has been included in a medical surveillance program lasting at least 6 months. The workers were followed up within a protocol that included psychiatric visits, psychotherapeutic interventions, visits by the occupational physician and medico-legal evaluations. Evaluation scales of disease severity and treatment efficacy (CGI) and overall functioning (GAF) were administered at the baseline and after 6 months of follow-up. RESULTS: The sample was mainly composed of nurses (44%) and nursing assistants (24%) and the most commonly diagnosed disorders were mood and anxiety disorders. Participation in the medical surveillance program with the implementation of specific therapeutic strategies and organizational interventions resulted in a statistically significant reduction in the severity of the disease and an improvement in overall functioning and made it possible to keep the job and place of work in almost all cases. DISCUSSION: The results of this experience allow us to affirm that the integration of skills is a valid tool both for the multidisciplinary diagnostic assessment and for the monitoring and management of workers with mental disability under periodic health surveillance.

Psychopathology of terrorists.

Terrorist behavior represents a subtype of human aggression probably determined by a combination of biological, psychological, and social factors, as well as by peculiar environmental influences and group dynamics. As regards terrorists' psychological characteristics, the available studies (mostly carried out with no sound scientific design) have failed to identify the common or typical pathological personality traits of modern terrorists. The popular opinion that terrorists must be insane or psychopathic is still widespread; however, no evidence exists that terrorist behavior may be caused either by prior or current psychiatric disorders or psychopathy. Not surprisingly, some theories have proposed social factors and non-pathological psychological traits as predisposing elements for terrorist acts, but they generally lack of empirical validation. Moreover, most of these theories do not explain why, even if so many people are exposed to the same social factors or show the same psychological traits, only a tiny minority of them join a terrorist group. Therefore, it is mandatory that systematic and scientific investigations be carried out in order to understand the possible bases for terrorist aggression, including the early detection of possibly associated psychopathology, and to design an appropriate counterterrorism prevention policy.

The mind of suicide terrorists.

After reviewing the available literature about the main hypotheses on suicide terrorism and the psychological characteristics of terrorists that have been proposed throughout the years, the present authors have put forward some personal considerations on what the distinctive traits of today's suicide bombers might be. In spite of the heterogeneity and paucity of "real" data, it is evident that there is no peculiar familial, educational, or socioeconomic factors that may account for religious radicalization leading to suicide terrorism. On the contrary, some common psychological features can be highlighted: such as isolation, feelings of emptiness, cold rationality, a lack of empathy, and a lust for martyrdom and death. To die to kill: this is the core feature, a sort of organizer that can twist higher cognitive and emotional processes, resulting in the supreme and highly rewarding suicidal and killing behaviors.

Work-related stress disorders: variability in clinical expression and pitfalls in psychiatric diagnosis.

BACKGROUND: Putative occupational stress-related psychiatric disorders are Adjustment Disorders (AD) and Post-Traumatic Stress Disorder (PTSD). Mood Disorders (MD) are not excluded but are unlikely to be identified as occupational diseases. The differential diagnosis between AD and MD is not easy and is based on strict categorical criteria. OBJECTIVES: The aim of this study  was to explore differences in personality and mood spectrum symptoms among workers investigated for occupational stress suffering from AD or MD. METHODS: Sixty-two patients with AD and 43 with MD were recruited and evaluated by means of rating scales for psychosocial occupational risk and work-related stress (WHS, CDL, OSQ), for sleep disturbances (PSQI), for personality disorders (SCID-II) and for mood spectrum symptoms (MOODS-SR). RESULTS: The diagnostic groups did not differ for WHS, OSQ and PSQI scores. The duration of exposure to stressful/adversative work situations was significantly higher in the MD group (p=0.03). Positive family psychiatric history (p=0.005), personality disorders (p=0.009) and pathological personality traits (p<0.0001) were significantly more frequent in the MD group. The MOODS-SR questionnaire total score (p=0.019) and the manic component score (p=0.001) but not the depressive score were significantly higher in the MD group. CONCLUSIONS: The present study suggests that  positive family psychiatric history, pathological personality traits and  spectrum manic symptoms represent markers of vulnerability and low resilience for workers exposed to occupational stress. These characteristics could weaken the etiological relationship between work-related stress and an initial  major depressive episode when it is under investigation as a possible occupational disease.

Plasma amyloid-ß levels in drug-resistant bipolar depressed patients receiving electroconvulsive therapy.

AIMS: Alterations of plasma amyloid-ß (Aß) peptides have been related to a high risk for cognitive impairment and dementia. The present study aimed to measure plasma Aß peptides (Aß40, Aß42) and the Aß40/Aß42 ratio in a sample of drug-resistant bipolar depressed patients, as well as to explore the possible correlation between biological parameters and clinical changes along an electroconvulsive therapy (ECT) course. METHODS: Aß40 and Aß42 were measured by means of an ELISA assay in 25 drug-resistant bipolar depressed patients before (T0) and 1 week after (T1) the end of ECT. The patients were clinically evaluated by means of the Hamilton Rating Scale for Depression, 21-item (HRSD-21), the Mini-Mental State Examination, and the Clinical Global Impressions-Severity of Illness Scale. RESULTS: Plasma Aß levels and the Aß40/Aß42 ratio were similar at T0 and T1. The Aß40/Aß42 ratio correlated positively with the HRSD total score at both T0 and T1. At T0, a negative correlation was found between the Aß40/Aß42 ratio and the improvement of depressive and cognitive symptoms. Moreover, remitters (n = 9; HRSD ≤10) showed a significantly lower Aß40/Aß42 ratio at T0 than nonremitters. CONCLUSION: The present data suggest that a low Aß40/Aß42 ratio might characterize a subgroup of depressed patients who respond to ECT, while higher values of this parameter seem to be typical of more severe cases of patients with cognitive impairment.

Neurodegeneration, ß-amyloid and mood disorders: state of the art and future perspectives.

OBJECTIVE: Depression may increase the risk of developing Alzheimer's disease (AD). Recent studies have shown modifications in blood beta-amyloid (Aß) levels in depressed patients. This literature review examines the potential relationship between Aß-mediated neurotoxicity and pathophysiology of mood disorders. DESIGN: We conducted a review of the literature focusing on recent studies reporting alterations of plasma and serum Aß peptides levels in patients suffering from mood disorders. RESULTS: Different data suggest that patients with mood disorders are at great risk of developing cognitive impairment and dementia. In particular, low plasma levels of Aß42 peptide and a high Aß40/Aß42 ratio have been found in depressed patients. In addition, changes in Aß protein levels in patients with mood disorders have been associated with the severity of cognitive impairment and correlated positively with the number of episodes and severity of illness course. CONCLUSIONS: Given the intriguing association between change in plasma level of Aß, depression and cognitive impairment, future work should focus on the relationship between Aß peripheral level(s), biomarkers of neurodegeneration and development of dementia in patients affected by mood disorders.

Comparison between Standard Expository Cognitive Behavioral Therapy (CBT-E) and Immersive Virtual Reality CBT (CBT-VR) for Rehabilitation of Patients Affected by Occupational Stress Disorders: Study Protocol.

Work-related stress presents a significant impact on work performance and physical health. It has been associated with the onset of a multitude of symptoms that can lead to occupational stress diseases, namely Adjustment Disorder and Post-Traumatic Stress Disorder. The literature has evidenced that "exposure therapy" of cognitive-behavioral training (CBT-E) seems to be the most effective technique to manage stress symptoms, including work stress diseases, and several studies have considered Virtual Reality (VR) as an adjuvant tool to exposure-based psychotherapy (CBT-VR) for the treatment of multiple psychiatric disorders. The aim of this study is to evaluate the effectiveness of CBT with exposure to stressful work scenarios in imaginative (CBT-E) and in immersive virtual reality (CBT-VR) scenarios in a group of workers affected by work-related stress disorders and compare the clinical and physiological outcomes between the two exposure techniques. A long-term goal would be to develop an evidence-based rehabilitation program as a treatment for the reintegration into work of patients affected by these psychiatric disorders.

Methodological approach to depressive symptoms in fibromyalgia patients.

OBJECTIVES: Depression is a common comorbid condition in fibromyalgia (FM) and a major contributor to poor quality of life and disability. However, depression can be difficult to assess in patients with FM due to overlapping symptoms between the two conditions. This review aims to present the most used rating scales for depression in FM patients by discussing their potential drawbacks. Moreover, we aimed to discuss the possible approach to mood symptoms in FM patients according to the mood spectrum model. METHODS: We included the main scales that have been used previously to assess depression in FM according to the literature data. Then, we reviewed the studies exploring the prevalence and the impact of sub-threshold mood symptoms on FM patients. RESULTS: Rating scales for depression such as the Hamilton Rating Scale for Depression, the Hospital Anxiety and Depression Scale, the Center for Epidemiologic Studies Depression Scale, the Beck Depression Inventory, the Montgomery Asberg Depression Rating Scale and the Zung Self-Rating Depression Scale have been largely used. However, almost all these instruments could suffer from a criterion contamination bias by somatic symptoms of chronic pain patients. Many studies have shown a critical role of sub-threshold mood psychopathology on worsening quality of life, disability and pain in FM patients. Specific questionnaires (Mood Spectrum Self-Report [MOODS-SR]) for subsyndromal phenomenology have been validated and used also in patients with medical diseases. CONCLUSIONS: The need of a careful screening of depressive symptoms and of their proper management is primary in FM. In our opinion instruments like MOODS-SR are particularly suitable for screening FM patients because they allow to recognise also sub-threshold mood symptoms with minimal contamination by somatic conditions.

Depressive symptoms in Parkinson's disease.

OBJECTIVE: We aimed to investigate the relationship between the presence and severity of depression and the degree of motor and functional disability in Parkinson's disease (PD). METHODS: One hundred twenty-two outpatients with PD were enrolled in a neurology department: 65 satisfied the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria for major depression, and 57 did not (PD-C). Depressive symptoms were assessed by means of the Hamilton Rating Scale for Depression (HRSD), and the PD severity was assessed according to the Hoehn and Yahr System. Activities of daily living and motor symptoms were measured by the Unified PD Rating Scale (UPDRS), parts II and III. RESULTS: Twenty-nine patients had a mild depression (HRSD total score ranging between 8 and 17), 30 had a moderate depression (HRSD total score ranging between 18 and 24), and 6 had a severe depression (HRSD total score, ≥25). By comparing the 3 groups of patients, it emerged that those with a severe depression showed significantly higher scores at the UPDRS II, UPDRS III, and HY scales than did PD-C or patients with a mild depression. Moreover, patients with a moderate depression scored significantly higher on the UPDRS II, UPDRS III, and HY scales than did PD-C or those with a mild depression. CONCLUSIONS: Our findings suggest that depression and motor symptoms/well-being are highly intertwined in patients with PD.

A Medical Resident with a History of Alcohol Abuse and Suicidal Ideation: A Challenge for Both Psychiatry and Occupational Medicine in the Context of the First Wave of the COVID-19 Pandemic.

This case study draws attention to the hazards of physicians with a history of alcohol addiction and a particular psychopathology framework in the context of occupational health surveillance, particularly during the challenging working conditions brought about by the COVID-19 pandemic. The case involves a hospital resident in her thirties, with a previous history of addiction and attempts at suicide, who was assigned to a COVID-19 unit of an Italian hospital. In this case study, we discuss the preventive intervention put in place in order to protect physicians' health and work. What emerges is the key role that rapid substantive communications between specialists play in formulating an effective strategy for dealing with these conditions. We believe this case is noteworthy for the lessons that can be learned for tailoring prevention and treatment pathways for health care workers with addiction.

Do Autistic Traits Correlate with Post-Traumatic Stress and Mood Spectrum Symptoms among Workers Complaining of Occupational Stress?

The adult autism subthreshold spectrum model appears to be a useful tool for detecting possible vulnerability factors in order to develop mental disorders in the contest of work-related stress. The aim of the present study is to analyze the relationship between autism, mood, and post-traumatic spectrum in a cohort of subjects complaining of work-related stress before the COVID-19 pandemic. The authors carried out a retrospective investigation of both medical records and self-assessment tools of a sample of subjects evaluated at the Occupational Health Department of a University hospital in central Italy. Data showed significant correlations between the AdAS spectrum, TALS-SR, and MOODS total and domain scores. A multiple linear regression evidenced that both the AdAS spectrum and TAL-SR significantly predict the MOODS scores. In particular, mediation analysis showed both a direct and indirect, mediated by TALS-SR, effect of the AdAS Spectrum on the MOODS-SR. These results corroborate the role of autistic traits in influencing the traumatic impact of work-related stress and the development of mood spectrum symptoms.

Affective temperament and mood spectrum symptoms in workers suffering from work-related stress disorders.

INTRODUCTION: Adjustment Disorders (AD) which develop in response to work-related stressors represent a model of psychiatric occupational disease. Major Depressive Episodes (MDE) although often associated to work-related stressors are unlikely recognized by insurance institutes as occupational diseases. Affective temperament and mood spectrum symptoms are possible factors of vulnerability to stress. The aim of this study was to investigate if temperaments and mood spectrum symptoms had a different distribution among workers exposed to occupational stress and suffering from different psychiatric disorders (AD, MDE). METHODS: 156 AD and 97 MDE patients were recruited and evaluated with scales for perceived stress (PSM) and work-related stress (JCQ), for psychopathological symptoms (BDI-II, SAS), for affective temperament (TEMPS-A[P]) and for lifetime mood spectrum symptoms (MOODS-SR). Group comparisons and correlation analyses between variables were performed by parametric or non-parametric statistical tests according to variables distribution. RESULTS: The diagnostic groups did not differ for perceived and occupational stress levels. MDE patients reported significantly higher BDI-II score and MOODS-SR scores than AD ones. The hyperthymic temperament was significantly more frequent in AD than in MDE group. The hyperthymic score, differently from other dimensions of temperament and from mood spectrum components, negatively correlated or did not correlate with psychopathological symptoms severity and perceived stress levels. LIMITATIONS: Predictive limitation because of cross-sectional design. CONCLUSIONS: The hyperthymic temperament as opposed to lifetime subtreshold mood symptoms appears to be more represented in patients suffering from occupational AD than in MDE ones. Acknowledging vulnerability factors to job stress could support clinicians in occupational diseases prevention and management.

Evaluation of the Anti-Spike (RDB) IgG Titer among Workers Employed at the University of Pisa Vaccinated with Different Types of SARS-CoV-2 Vaccines.

With the development of SARS-CoV-2 vaccines, many authors started evaluating the immunization efficacy of the available vaccines mainly through sero-positivity tests or by a quantitative assessment of the IgG against the spike protein of SARS-CoV-2 virus in vaccinated subjects. In this work, we compared the titers resulting from vaccination and tried to understand the potential factors affecting the immune response to the available SARS-CoV-2 vaccines. This study was conducted on 670 volunteers employed at the University of Pisa and undergoing a health surveillance program at the University Hospital of Pisa. For each participant, 10 mL of blood, information about contacts with confirmed cases of COVID-19, age, sex, SARS-CoV-2 vaccination status, previous SARS-CoV-2 infection and symptoms, type of vaccine and the date of administration were collected. In the multivariate analysis, the type of vaccine, the presence of symptoms in SARS-CoV-2 positive individuals, and the distance from the second dose significantly affected the antibody titer; the combined vaccination resulted in a faster decay over time compared with the other types of vaccination. No significant differences were observed between Spikevax and Comirnaty (p > 0.05), while the antibody levels remain more stable in subjects undergoing Vaxzevria vaccination (p < 0.01) compared with mRNA-based ones.

Irritable Bowel Syndrome prevalence and work ability in a sample of healthcare workers exposed to occupational stress.

OBJECTIVE: Occupational stress represents a significant precipitating factor in different diseases but its role in Irritable Bowel Syndrome (IBS) needs to be clarified. The present cross-sectional study aimed at investigating the prevalence of IBS diagnosis in a sample of health workers and exploring the potential relationships between IBS, work-related stress levels and work ability. METHODS: 653 health workers undergoing periodical occupational health surveillance at the Occupational and Preventive Medicine Unit of a major University Hospital in central Italy, were consecutively recruited and screened for IBS diagnosis, according to ROMA IV criteria. The rating scales IBS Severity Scoring System (IBS-SSS), Demand-Control-Support Questionnaire (DCSQ) and Work Ability Index (WAI) were used to assess respectively IBS severity, occupational stress and work ability levels. RESULTS: IBS prevalence in the sample was 16.8%. Participants suffering from IBS were characterized by a higher prevalence of psychiatric diagnosis and sleep disturbances, higher levels of job strain and isostrain as well as by lower levels of work ability compared to non affected subjects. Moreover, the severity of IBS correlated positively with occupational stress and both were negatively associated with work ability. CONCLUSIONS: The present results suggest the need for preventive, organizational and management strategies at workplace aimed at protecting the health and well-being but also productivity of the worker with IBS.

Mental health of Health Care Workers (HCWs): a review of organizational interventions put in place by local institutions to cope with new psychosocial challenges resulting from COVID-19.

The COVID-19 outbreak has been associated with significant occupational stressors and challenges for healthcare workers (HCWs) including the risk of exposure to SARS-CoV-2. Many reports from all over the world have already found that HCWs have significant levels of self-reported anxiety, depression and even symptoms of post-traumatic stress disorder. Therefore, supporting mental health of HCWs is a crucial part of the public health response to the COVID-19 pandemic. The aim of the present review is to ascertain the interventions put in place worldwide in reducing stress in HCWs during the COVID-19 outbreak. We evidenced how only few countries have published specific psychological support intervention protocols for HCWs. All programs were developed in university associated hospitals and highlighted the importance of multidisciplinary collaboration. All of them had as their purpose to manage the psychosocial challenges to HCW's during the pandemic in order to prevent mental health problems.Whether one program offers distinct benefit compared to the others cannot be known given the heterogeneity of the protocols and the lack of a rigorous protocol and clinical outcomes. Further research is crucial to find out the best ways to support the resilience and mental well-being of HCWs.

Associations between brain-derived neurotrophic factor plasma levels and severity of the illness, recurrence and symptoms in depressed patients.

BACKGROUND: There is increasing evidence that the brain-derived neurotrophic factor (BDNF) is involved in the pathophysiology of mood disorders and that its peripheral levels represent a reliable mirror of its concentration in the brain. The aim of the present study was to measure BDNF plasma levels in patients affected by major depression and to explore the possible relationship between the biological parameter and characteristics of the illness. METHOD: BDNF plasma levels were evaluated in 30 inpatients suffering from major depression, according to DSM-IV criteria, by means of a commonly employed ELISA method. The clinical characteristics were assessed by the Hamilton Rating Scale for Depression (HRSD) and the Clinical Global Impression Scale. RESULTS: BDNF plasma levels were significantly lower in the patients with the severest illness compared with the others, and the same was true for patients with dissociative symptoms, severe sleep disturbance and recurrent depression. A significant and negative correlation was observed between the biological parameter and the retardation factor score of the HRSD. CONCLUSION: These findings suggest that low BDNF levels are related to both recurrence and severity of depression, as well as to symptoms typical of dysfunctions of the hypothalamic-pituitary-adrenal axis.

Sociodemographic, clinical and criminological characteristics of a sample of Italian Volterra REMS patients.

BACKGROUND: In Italy the Law 9/2012 prescribed the total closure of forensic psychiatric hospitals (OPGs) and the conversion to a care model based on residential units in the community employing only clinical personnel (Residenze per l'Esecuzione delle Misure di Sicurezza - REMS) and fully integrated in public mental health services. The aim of this study is to report sociodemographic, clinical and criminological characteristics of patients admitted in Volterra REMS since it opened on 01/12/15 up to 31/12/17. METHODS: Sociodemographic and clinical information was collected from official documents (clinical files, ward reports) and from patients' personal health records. Psychiatric diagnoses were made by REMS psychiatrists according to the DSM-5 criteria. Criminological information was obtained from patients' criminal records. RESULTS: Volterra REMS patients' characteristics are similar to those of samples of OPGs patients (unmarried socially disadvantaged males with an average age of 40, no offsprings, low education, high rates of Schizophrenia Spectrum Disorders and medical comorbidity). However, the REMS model presents a very high turnover rate: during the study period 61 patients were admitted while 32 were discharged. Being assisted by public mental health services before committing the crime increased the probability of discharge. In non-EU patients long acting injectable antipsychotics were used more frequently than in community ones. Substance-Related Disorders are the main psychiatric comorbidity and resulted as being more frequent in bipolar patients than in other patients. CONCLUSIONS: Due to the high patients' turnover, we expect a progressive change in sociodemographic, clinical and criminological features of the REMS population. The REMS model provides a return for mentally disordered criminals to the care of local public mental health services which are recovering after many years some of their most challenging patients ensuring their deinstitutionalization and reintegration into society.

Plasma Brain-Derived Neurotrophic Factor (BDNF) and serum cortisol levels in a sample of workers exposed to occupational stress and suffering from Adjustment Disorders.

INTRODUCTION: Decreased plasma BDNF (pBDNF) levels have been proposed as a biomarker in illness phases of mood disorders. Serum cortisol (seC) levels are an index of energy mobilization and stress. The aim of this cross-sectional study was to evaluate pBDNF and seC levels in workers exposed to occupational stress and suffering from Adjustment Disorders (AD) compared to healthy workers. METHODS: Plasma BDNF and seC levels were measured by means of specific immunoassays in 64 AD patients and 38 healthy controls. Perceived and occupational stress was evaluated in patients and controls using the Psychological Stress Measure (PSM) and the Job Content Questionnaire (JCQ). Psychopatological symptoms in patients were assessed using specific rating scales. RESULTS: Plasma BDNF levels resulted significantly higher in patients than in controls, whereas no significant differences were found for seC levels. In patients but not in controls pBDNF levels showed a significant positive correlation with seC levels. Perceived stress levels were positively correlated with all psychopatological rating scales scores. CONCLUSIONS: BDNF could play a key role in the pathophysiology of stress-related disorders and its peripheral levels elevation could contribute to protect neurons under stress. Further research is needed focusing on biomarkers for stress-related disorders as a potential tool for the diagnosis and prevention of occupational diseases.