Duygudurum ve Anksiyete Bozukluklarında Psikonöroimmünolojik Süreçler ve Psikoterapi ile İlişkisi

Yıl 2022, , 86 - 97, 31.03.2022

Ceyhun Yılmaz , Gözde İkizer

https://doi.org/10.18863/pgy.943148

Öz

Duygudurum ve anksiyete bozukluklarının yaygınlık oranlarının yüksekliği ve bu bozukluklarla ilişkili işlev bozuklukları nedeniyle, bu bozuklukların daha iyi anlaşılması, önlenmesi ve tedavi edilmesi oldukça önemlidir. Psikolojik ve diğer biyolojik nedensel faktörlerin ve mekanizmaların yanı sıra, inflamatuar biyobelirteçlerin, özellikle de sitokinlerin, duygudurum ve anksiyete bozukluklarının kökeninde ve sürdürülmesinde rolü olduğu kabul edilmektedir. Buradan hareketle, birtakım çalışmalar psikoterapi müdahalelerinin sitokin düzeylerinin de dahil olduğu nöroimmünolojik parametreler üzerindeki etkisine odaklanmıştır. Bu derleme, duygudurum ve anksiyete bozuklukları ve bunların sağaltımında yaygın olarak kullanılan psikoterapi yaklaşımları ile ilişkili psikonöroimmünolojik faktörlerden, özellikle sitokin düzeylerindeki değişimleri tartışmayı hedeflemektedir. Alanyazındaki çalışmaların çoğunda ilgili bozukluklar için psikoterapi alan bireylerde özellikle pro-inflamatuar sitokinlerin düzeylerinin azaldığı gösterilirken, anti-inflamatuar sitokinlerin düzeylerinin ise yükseldiği bildirilmiştir. Yine de çalışma desenlerinin çeşitliliği çalışmalar arasında bulguların kıyaslanmasında ve çalışmaların çoğunun kesitsel desene sahip olması psikiyatrik semptomatoloji ve immünolojik parametreler arasındaki neden-sonuç ilişkilerinin anlaşılmasında zorluk yaratmaktadır. Psikonöroimmünoloji alanında yapılacak gelecek çalışmalarda örneklem gruplarının ve ölçüm yöntemlerinin dikkatle belirlenmesi önemlidir. Ayrıca belirli psikoterapi yaklaşımlarının anti-inflamatuar etkileri olabileceğini gösteren bulguların bu yaklaşımlara özgü olup olmadığının anlaşılması için daha fazla sayıda psikoterapi sonuç çalışmasına ihtiyaç duyulmaktadır.

Anahtar Kelimeler

Duygudurum bozuklukları, kaygı bozuklukları, psikoterapi, inflamasyon, sitokinler

Psychoneuroimmunological Processes in Mood and Anxiety Disorders and Their Relation with Psychotherapy

Öz

Given high prevalence of mood and anxiety disorders and associated dysfunctions, better understanding, preventing, and treating these disorders are crucial. Along with psychological and other biological causal factors and mechanisms, inflammatory biomarkers, especially cytokines, have also been implicated in etiology and maintenance of mood and anxiety disorders. In the literature, it is generally acknowledged that there is a generalized inflammatory state in these disorders. Thus, several studies have focused on the impact of psychotherapy interventions on neuroimmunological parameters including cytokine levels. This review aims to discuss psychoneuroimmunological factors, especially changes in cytokine levels associated with mood and anxiety disorders and psychotherapy approaches which are commonly used for their treatment. Especially levels of pro-inflammatory cytokines have been shown in majority of those studies to be decreased while levels of anti-inflammatory cytokines have been reported to be elevated in individuals having psychotherapy for these disorders. Nevertheless, variability in study designs and cross-sectional designs in most studies create challenges for comparing results between studies and understanding cause-effect relationships between psychiatric symptomatology and immunological parameters. It is important to carefully determine sample groups and measurement methods in future studies in the field of psychoneuroimmunology. In addition, more studies are needed to figure out if findings showing that certain psychotherapeutic approaches can have anti-inflammatory effects are specific to those approaches or not.

Anahtar Kelimeler

Mood disorders, anxiety disorders, psychotherapy, inflammation, cytokines

Kaynakça

• Ader R, Cohen N. (1975) Behaviorally conditioned immunosuppression. Psychosom Med, 37(4):333-40.
• American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders, 5th ed. Arlington, VA, American Psychiatric Association.
• Amerikan Psikoloji Birliği (2021) Psychological treatments. Available from: URL:https://div12.org/psychological-treatments Accessed date:21.05.2021.
• Anthony IC, Ramage SN, Carnie FW, Simmonds P, Bell JE. (2005) Influence of HAART on HIV-related CNS disease and neuroinflammation. J Neuropathol Exp Neurol, 64(6):529-36.
• Aslan Ş (2018) Tek atak ve tekrarlayan depresyon tanili hastalarda total anti̇oksi̇dan sevi̇yesi̇ (tas), total oksi̇dan sevi̇yesi̇ (tos) ve si̇toki̇n düzeyleri̇ni̇n karşılaştırılması i̇le i̇laç etki̇si̇ni̇n değerlendi̇ri̇lmesi̇ (Uzmanlık tezi). Pamukkale, Pamukkale Üniversitesi.
• Barbosa IG, Machado-Vieira R, Soares JC, Teixeira AL. (2014) The immunology of bipolar disorder. Neuroimmunomodulation, 21(2-3):117-22.
• Bayat S, Alipour A, Aghayosefi A, Malayeri R. (2020) The effectiveness of mindfulness based cognitive therapy on of interleukin 6 (IL-6) and biological age in female breast cancer patients. Razi Journal of Medical Sciences, 27(1):1-8.
• Beishuizen A, Thijs LG. (2003) Endotoxin and the hypothalamo-pituitary-adrenal (HPA) axis. J Endotoxin Res, 9(1):3-24.
• Berthold-Losleben M, Heitmann S, Himmerich H. (2009) Anti-inflammatory drugs in psychiatry. Inflamm Allergy Drug Targets, 8(4):266-76.
• Brietzke E, Stertz L, Fernandes BS, Kauer-Sant’Anna M, Mascarenhas M, Vargas AE ve ark.(2009) Comparison of cytokine levels in depressed, manic and euthymic patients with bipolar disorder. J Affect Disord, 116(3):214-7.
• Capuron L, Neurauter G, Musselman DL, Lawson DH, Nemeroff CB, Fuchs D ve ark. (2003) Interferon-alpha–induced changes in tryptophan metabolism: relationship to depression and paroxetine treatment. Biol Psychiatry, 54(9):906-14.
• Castle DJ, Kulkarni J, Abel KM (2006) Mood and anxiety disorders in women. Cambridge, Cambridge University Press.
• Choi KW, Jang EH, Kim AY, Kim H, Park MJ, Byun S et al. (2021) Predictive inflammatory biomarkers for change in suicidal ideation in major depressive disorder and panic disorder: A 12-week follow-up study. J Psychiatr Res, 133:73-81.
• Costello H, Gould RL, Abrol E, Howard R. (2019) Systematic review and meta-analysis of the association between peripheral inflammatory cytokines and generalised anxiety disorder. BMJ Open, 9:e027925.
• Craighead WE, Miklowitz DJ, Craighead LW (2017) Psychopathology: history, diagnosis, and empirical foundations, 3rd ed. Hoboken, New Jersey, John Wiley & Sons.
• Cristea IA, Karyotaki E, Hollon SD, Cuijpers P, Gentili C. (2019) Biological markers evaluated in randomized trials of psychological treatments for depression: a systematic review and meta-analysis. Neurosci Biobehav Rev, 101:32-44.
• Da Silva GDG, Wiener CD, Barbosa LP, Araujo JMG, Molina ML, San Martin P ve ark. (2016) Pro-inflammatory cytokines and psychotherapy in depression: results from a randomized clinical trial. J Psychiatr Res, 75:57-64.
• Dahl J, Ormstad H, Aass HCD, Malt UF, Bendz LT, Sandvik L ve ark. (2014) The plasma levels of various cytokines are increased during ongoing depression and are reduced to normal levels after recovery. Psychoneuroendocrinology, 45:77-86.
• Dahl J, Ormstad H, Aass HCD, Sandvik L, Malt UF, Andreassen OA. (2016) Recovery from major depressive disorder episode after non‐pharmacological treatment is associated with normalized cytokine levels. Acta Psychiatr Scand, 134(1):40-7.
• Dantzer R, Aubert A, Bluthe RM, Gheusi G, Cremona S, Laye S, Konsman JP, Parnet P, Kelley KW. (1999a) Mechanisms of the behavioural effects of cytokines. In Cytokines, Stress, and Depression (Eds R Dantzer, EE Wollman, R Yirmiya):83-105. New York, NY, Springer.
• Dantzer R, Wollman EE, Vitkovic L, Yirmiya R. (1999b) Cytokines, stress, and depression. In Cytokines, Stress, and Depression (Eds R Dantzer, EE Wollman, R Yirmiya):317-29. New York, NY, Springer.
• Daruna JH (2012) Introduction to psychoneuroimmunology, 2nd ed. San Diego, Elsevier Academic Press.
• Deczkowska A, Baruch K, Schwartz M. (2016) Type I/II interferon balance in the regulation of brain physiology and pathology. Trends Immunol, 37(3):181-92.
• Dowlati Y, Herrmann N, Swardfager W, Liu H, Sham L, Reim EK ve ark. (2010) A meta-analysis of cytokines in major depression. Biol Psychiatry, 67(5):446-57.
• Duivis HE, Vogelzangs N, Kupper N, de Jonge P, Penninx BWJH. (2013) Differential association of somatic and cognitive symptoms of depression and anxiety with inflammation: findings from the Netherlands Study of Depression and Anxiety (NESDA). Psychoneuroendocrinology, 38:1573-85.
• Eisendrath SJ, Gillung E, Hartzler A, James-Myers M, Wolkowitz O. (2016) Mindfulness-based cognitive therapy associated with decreases in c-reactive protein in major depressive disorder: A pilot study. J Altern Complement Integr Med, 2:010.
• Ekdahl CT. (2012) Microglial activation–tuning and pruning adult neurogenesis. Front Pharmacol, 3:41.
• Euteneuer F, Dannehl K, Del Rey A, Engler H, Schedlowski M, Rief W. (2017) Immunological effects of behavioral activation with exercise in major depression: An exploratory randomized controlled trial. Transl Psychiatry, 7(5):e1132.
• Fiedorowicz J. (2019) Changes in inflammation with treatment for bipolar II depression: Pilot trial data on differential effects of psychotherapy and medication. Neurol Psychiatry Brain Res, 33:112-8.
• Foldager L, Kohler O, Steffensen R, Thiel S, Kristensen AS, Jensenius JC, Mors O. (2014) Bipolar and panic disorders may be associated with hereditary defects in the innate immune system. J Affect Disord, 164:148-54.
• Fruscella P, Sottocorno M, Di Braccio M, Diomede L, Piccardi N, Cagnotto A ve ark. (2001) 1,5-Benzodiazepine tricyclic derivatives exerting anti-inflammatory effects in mice by inhibiting interleukin-6 and prostaglandinE(2) production. Pharmacol Res, 43(5):445-51.
• Gałecki P, Mossakowska-Wójcik J, Talarowska M. (2018) The anti-inflammatory mechanism of antidepressants–SSRIs, SNRIs. Prog Neuropsychopharmacol Biol Psychiatry, 80(Pt C):291-4.
• Gazal M, Souza LD, Fucolo BA et al. (2013) The impact of cognitive behavioral therapy on IL-6 levels in unmedicated women experiencing the first episode of depression: A pilot study. Psychiatry Research, 209:742-5.
• GBD 2017 Causes of Death Collaborators. (2018) Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet, 392(10159):1736-88.
• Harley J, Luty S, Carter J, Mulder R, Joyce P. (2010) Elevated C-reactive protein in depression: a predictor of good long-term outcome with antidepressants and poor outcome with psychotherapy. J Psychopharmacol, 24(4):625-6.
• Hannestad J, DellaGioia N, Bloch M. (2011) The effect of antidepressant medication treatment on serum levels of inflammatory cytokines: a meta-analysis. Neuropsychopharmacol, 36:2452-9.
• Harrison NA, Brydon L, Walker C, Gray MA, Steptoe A, Critchley HD. (2009) Inflammation causes mood changes through alterations in subgenual cingulate activity and mesolimbic connectivity. Biol Psychiatry, 66(5):407-14.
• Heneka MT, Carson MJ, El Khoury J, Landreth GE, Brosseron F, Feinstein DL ve ark. (2015) Neuroinflammation in Alzheimer's disease. Lancet Neurol, 14(4):388-405.
• Himmerich H, Patsalos O, Lichtblau N, Ibrahim MAA, Dalton B. (2019) Cytokine research in depression: principles, challenges, and open questions. Front Psychiatry, 10:30.
• Hirsch EC, Vyas S, Hunot S. (2012) Neuroinflammation in Parkinson's disease. Parkinsonism Relat Disord, 18(Suppl 1):210-2.
• Hofmann SG, Sawyer AT, Fang A, Asnaani A. (2012) Emotion dysregulation model of mood and anxiety disorders. Depress Anxiety, 29:406-16.
• Hoge EA, Brandstetter K, Moshier S, Pollack MH, Wong KK, Simon NM. (2009) Broad spectrum of cytokine abnormalities in panic disorder and posttraumatic stress disorder. Depress Anxiety, 26(5):447-55.
• Hoge EA, Bui E, Palitz SA, Schwarz NR, Owens ME, Johnston JM ve ark. (2018) The effect of mindfulness meditation training on biological acute stress responses in generalized anxiety disorder. Psychiatry Res, 262:328-32.
• Hooley JM, Butcher JN, Nock MK, Mineka S (2017) Abnormal psychology, 17th ed. England, Pearson Education Limited.
• Hou R, Baldwin DS. (2012) A neuroimmunological perspective on anxiety disorders. Hum Psychopharmacol, 27(1):6-14.
• Hovatta I, Juhila J, Donner J. (2010) Oxidative stress in anxiety and comorbid disorders. Neurosci Res, 68(4):261-75.
• Kalelioglu T, Genc A, Karamustafalıoğlu N. (2017) İki uçlu bozukluk ve inflamasyon. J Mood Disord, 7:54-64.
• Kalsi N, Altavilla D, Tambelli R, Aceto P, Trentini C, Di Giorgio C, Lai C. (2017) Neural correlates of outcome of the psychotherapy compared to antidepressant therapy in anxiety and depression disorders: A meta-analysis. Front Psychol, 8:927.
• Karabulut S, Taşdemir İ, Akcan U, Küçükali Cİ, Tüzün E, Çakır S. (2019)Erken evre ve kronik bipolar bozukluk hastalarında i̇nflamasyon ve nörodejenerasyon bulguları. Türk Psikiyatri Derg, 30(2):75-81.
• Kauer-Sant'Anna M, Kapczinski F, Andreazza AC, Bond DJ, Lam RW, Young LT ve ark. (2009) Brain-derived neurotrophic factor and inflammatory markers in patients with early-vs. late-stage bipolar disorder. Int J Neuropsychopharmacol, 12(4):447-58.
• Kaufman J, Charney D. (2000) Comorbidity of mood and anxiety disorders. Depress Anxiety, 12(S1):69-76.
• Keri S, Szabo C, Kelemen O. (2014) Expression of Toll-Like Receptors in peripheral blood mononuclear cells and response to cognitive behavioral therapy in major depressive disorder. Brain Behav Immun, 40:235-43.
• Kiecolt-Glaser JK, Derry HM, Fagundes CP. (2015) Inflammation: depression fans the flames and feasts on the heat. Am J Psychiatry, 172:1075-91.
• Kiecolt-Glaser JK, Glaser R. (1992) Psychoneuroimmunology: can psychological interventions modulate immunity? J Consult Clin Psychol, 60(4):569-75.
• Kiecolt-Glaser JK, McGuire L, Robles TF, Glaser R. (2002) Psychoneuroimmunology: psychological influences on immune function and health. J Consult Clin Psychol, 70(3):537-47.
• Klimov VV (2019) From basic to clinical immunology. Switzerland, Springer International Publishing.
• Koh KB, Lee Y. (2004) Reduced anxiety level by therapeutic interventions and cell-mediated immunity in panic disorder patients. Psychother Psychosom, 73:286-292.
• Krogh J, Benros ME, Jørgensen MB, Vesterager L, Elfving B, Nordentoft M. (2014) The association between depressive symptoms, cognitive function, and inflammation in major depression. Brain Behav Immun, 35:70-6.
• Lee STH. (2020) Inflammation, depression, and anxiety disorder: A population-based study examining the association between Interleukin-6 and the experiencing of depressive and anxiety symptoms. Psychiatry Res, 285:112809.
• Leonard BE (2010) The concept of depression as a dysfunction of the immune system. In Depression: from psychopathology to pharmacotherapy. (Eds JF Cryan, BE Leonard):53-71. Switzerland: Karger Publishers.
• Liukkonen T, Räsänen P, Jokelainen J, Leinonen M, Järvelin MR, Meyer-Rochow V ve ark. (2011) The association between anxiety and C-reactive protein (CRP) levels: results from the Northern Finland 1966 birth cohort study. Eur Psychiatry, 26(6):363-369.
• Lopresti AL. (2017) Cognitive behaviour therapy and inflammation: a systematic review of its relationship and the potential implications for the treatment of depression. Aust N Z J Psychiatry, 51:565-82.
• Lopresti AL, Maker GL, Hood SD, Drummond PD. (2014) A review of peripheral biomarkers in major depression: the potential of inflammatory and oxidative stress biomarkers. Prog Neuropsychopharmacol Biol Psychiatry, 48:102-11.
• Manassis K, Bradley SJ. (1994) The development of childhood anxiety disorders: toward an integrated model. J Appl Dev Psychol, 15(3):345-66.
• Memon AA, Sundquist K, Ahmad A, Wang X, Hedelius A, Sundquist J. (2017) Role of IL-8, CRP and epidermal growth factor in depression and anxiety patients treated with mindfulness-based therapy or cognitive behavioral therapy in primary health care. Psychiatry Res, 254:311-6.
• Messina I, Sambin M, Palmieri A, Viviani R. (2013) Neural correlates of psychotherapy in anxiety and depression: a meta-analysis. PLoS One, 8(9):e74657.
• Moreira FP, de Azevedo Cardoso T, Mondin TC, de Mattos Souza LD, Silva R, Jansen K ve ark. (2015) The effect of proinflammatory cytokines in Cognitive Behavioral Therapy. J Neuroimmunol, 285:143-6.
• Morin-Alain V, Larouche E, Chouinard AM, Audet MC, Goulet S, Rousseau LS, Hudon C. (2020). Effects of a mindfulness-based intervention on circulating cytokine levels in individuals with amnestic mild cognitive impairment: a pilot study. OBM Integrative and Complementary Medicine, 5(2):1-24.
• Myint A-M. Inflammation, neurotoxins and psychiatric disorders. In: Inflammation in psychiatry (vol. 28), Halaris A, Leonard BE eds. Basel, Switzerland: Karger Publishers, 2013:61-74.
• Najjar S, Pearlman DM, Alper K, Najjar A, Devinsky O. (2013) Neuroinflammation and psychiatric illness. J. Neuroinflammation, 10(1):1-24.
• Nassar A, Azab AN. (2014) Effects of lithium on inflammation. ACS Chem Neurosci, 5(6):451-8.
• Olness K, Ader R. (1992) Conditioning as an adjunct in the pharmacotherapy of lupus erythematosus. J Dev Behav Pediatr, 13(2):124-5.
• Özen ME, Örüm MH, Yılmaz MB, Kalenderoğlu A. (2019) İnflamatuar biyobelirteçler açısından bipolar bozukluk tip 1 tanılı hastaların sağlıklı kontrollerle karşılaştırılması. ADYÜ Sağlık Bilimleri Derg, 5:1352-60.
• Paradise MB, Naismith SL, Norrie LM, Graeber MB, Hickie IB. (2012) The role of glia in late-life depression. Int Psychogeriatr, 24(12):1878-90.
• Park KM, Bowers WJ. (2010) Tumor necrosis factor-alpha mediated signaling in neuronal homeostasis and dysfunction. Cell Signal, 22(7):977-83.
• Petrowski K, Wichmann S, Kirschbaum C. (2018). Stress-induced pro- and antiinflammatory cytokine concentrations in panic disorder patients. Psychoneuroendocrinology, 94:31-37.
• Punchard NA, Whelan CJ, Adcock I. (2004) The journal of inflammation. J Inflamm, 1(1):1.
• Quagliato LA, Nardi AE. (2018) Cytokine alterations in panic disorder: A systematic review. J Affect Disord, 228:91-6.
• Raison CL, Miller AH. (2003) When not enough is too much: the role of insufficient glucocorticoid signaling in the pathophysiology of stress-related disorders. Am J Psychiatry, 160(9):1554-65.
• Ressler K, Mayberg H. (2007) Targeting abnormal neural circuits in mood and anxiety disorders: from the laboratory to the clinic. Nat Neurosci, 10:1116-24.
• Rosenberg GA. (2002) Matrix metalloproteinases and neuroinflammation in multiple sclerosis. Neuroscientist, 8(6):586-95.
• Rosenblat JD, Cha DS, Mansur RB, McIntyre RS. (2014) Inflamed moods: a review of the interactions between inflammation and mood disorders. Prog Neuropsychopharmacol Biol Psychiatry, 53:23-34.
• Sartori SB, Singewald N. (2019) Novel pharmacological targets in drug development for the treatment of anxiety and anxiety-related disorders. Pharmacology & Therapeutics, 204:107402.
• Schiele MA, Gottschalk MG, Domschke K. (2020) The applied implications of epigenetics in anxiety, affective and stress-related disorders - a review and synthesis on psychosocial stress, psychotherapy and prevention. Clin Psychol Rev, 77:101830.
• Shields GS, Spahr CM, Slavich GM. (2020) Psychosocial interventions and immune system function: A systematic review and meta-analysis of randomized clinical trials. JAMA Psychiatry, 77(10):1031-43.
• Stertz L, Magalhaes PV, Kapczinski F. (2013) Is bipolar disorder an inflammatory condition? The relevance of microglial activation. Curr Opin Psychiatry, 26(1):19-26.
• Straub J, Plener PL, Sproeber N, Sprenger L, Koelch MG, Groen G, Abler B. (2015) Neural correlates of successful psychotherapy of depression in adolescents. J Affect Disord, 183:239-46.
• Tükel, R, Arslan BA, Ertekin BA, Ertekin E, Oflaz S, Ergen A, İsbir T. (2012) Decreased IFN-γ and IL-12 levels in panic disorder. J. Psychosomatic Res, 73(1):63-7.
• Van Duinen M, Schruers K, Griez E, Maes M. (2004) Neuroimmunological parameters in panic disorder. Acta Neuropsychiatrica, 16(2):94-100.
• Valkanova V, Ebmeier KP, Allan CL. (2013) CRP, IL-6, and depression: a systematic review and meta-analysis of longitudinal studies. J Affect Disord, 150:736-44.
• Varma GS. (2014) Major depresif bozuklukta nöroinflamatuvar hipotez. Psikiyatride Guncel Yaklasimlar, 6(1):1-9.
• Vogelzangs N, Beekman ATF, De Jonge P, Penninx BWJH. (2013) Anxiety disorders and inflammation in a large adult cohort. Transl Psychiatry, 3(4):e249.
• Wagner EYN, Wagner JT, Glaus J, Vandeleur CL, Castelao E, Strippoli MPF ve ark. (2015) Evidence for chronic low-grade systemic inflammation in individuals with agoraphobia from a population-based prospective study. PLoS One, 10(4):e0123757.
• Walsh E, Eisenlohr-Moul T, Baer R. (2016) Brief mindfulness training reduces salivary IL-6 and TNF-α in young women with depressive symptomatology. J Consult Clin Psychol, 84(10):887-97.
• Wampold BE. (2007) Psychotherapy: The humanistic (and effective) treatment. Am Psychol, 62(8):857-73.
• Watson D. (2005) Rethinking the mood and anxiety disorders: A quantitative hierarchical model for DSM-V. J Abnorm Psychol, 114:522-36.
• World Health Organization (2017) Depression and other common mental disorders: Global health estimates. Available from: URL:https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf Accessed date:21.05.2021.
• Yoon HK, Kim YK, Lee HJ, Kwon DY, Kim L. (2012) Role of cytokines in atypical depression. Nord J Psychiatry, 66(3):183-8.
• Yuan N, Chen Y, Xia Y, Dai J, Liu C. (2019) Inflammation-related biomarkers in major psychiatric disorders: a cross-disorder assessment of reproducibility and specificity in 43 meta-analyses. Transl Psychiatry, 9:233.
• Zeppegno P, Krengli M, Ferrante D, Bagnati M, Burgio V, Farruggio S, Rolla R, Gramaglia C, Grossini E. (2021) Psychotherapy with music intervention improves anxiety, depression and the redox status in breast cancer patients undergoing radiotherapy: a randomized controlled clinical trial. Cancers, 13(8):1752.
• Ziemssen T, Kern S. (2007) Psychoneuroimmunology–cross-talk between the immune and nervous systems. J Neurol, 254(2):II8-II11.
• Zou Z, Zhou B, Huang Y, Wang J, Min W, Li T. (2020) Differences in cytokines between patients with generalised anxiety disorder and panic disorder. J Psychosom Res, 133:109975.