Background Dermatological illness can affect the quality of life and may coexist with psychiatric disorders. Objective The aim of this review was to systematically evaluate the published evidence of any psychiatric disorders that may coexist with chronic urticaria (CU) and any effect psychiatric interventions may have on CU. Methods Following the Cochrane guidance, we conducted a systematic literature search using web-based search engines provided by PubMed (for Medline database), Google Scholar and Scopus for studies that have investigated the existence of psychiatric comorbidity in patients with CU. To be included, a study had to possess features, such as: (1) distinction between chronic urticaria and allergic conditions, (2) direct collection of diagnostic psychiatric data by using clinical interview and standardized questionnaires, (3) International Classification of Disorders criteria or the Diagnostic and Statistical Manual of Mental Disorders criteria for the diagnosis of mental disorders, and (4) manuscripts written or published in the English language. Unpublished research and research in progress were not included. All the eligible studies were scrutinized for any reported psychiatric interventions that had any effect on CU. The systematic review has been registered on PROSPERO (registration number CRD42019122811) and was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Results Twenty-five studies were identified. Almost one out of three CU patients have at least one underlying psychiatric disorder. None of the studies clarified whether the psychiatric disorders pre-existed the CU onset, and no association was found between CU severity and duration, and psychological functioning. Only one case report and two case series mentioned that treatment of psychiatric disorders with either anti-depressants, anti-anxiety drugs or psychological interventions might result in improvement of urticaria. Conclusions Patients with CU frequently experience psychiatric disorders. This highlights the need for a multidisciplinary therapeutic approach involving prompt recognition and management of any potential psychiatric disorder in addition to urticaria treatment. Further studies are needed to assess whether psychiatric disorders coexist with CU independently or follow urticaria onset and whether any psychological or psychiatric intervention may help in CU control.

ImportanceTreatment-resistant depression (TRD) is common in older adults. Bilateral repetitive transcranial magnetic stimulation (rTMS) of the dorsolateral prefrontal cortex for 48 minutes has demonstrated efficacy in TRD. Theta burst stimulation (TBS), a newer form of rTMS, can also be delivered bilaterally using left intermittent TBS and right continuous TBS for only 4 minutes.ObjectiveTo establish the effectiveness and tolerability of TBS compared with standard rTMS in older adults with TRD.Design, Setting, and ParticipantsIn this randomized noninferiority trial with open treatment and blinded assessors, recruitment occurred between December 2016 and March 2020. The trial was conducted at the Centre for Addiction and Mental Health in Toronto, Ontario, Canada and included outpatients 60 years and older with a diagnosis of depression, moderate severity, and nonresponse to 1 or more antidepressant trial of adequate dosage and duration or intolerance of 2 or more trials.InterventionsParticipants were randomized to receive a course of 4 to 6 weeks of either bilateral standard rTMS or TBS.Main Outcomes and MeasuresThe primary outcome measure was change in Montgomery-Åsberg Depression Rating Scale; secondary outcome measures included the 17-item Hamilton Rating Scale for Depression, Quick Inventory of Depressive Symptomatology (16-item) (self-report), and dropout rates. A noninferiority margin of 2.75 points was used for the primary outcome. All participants who attained the primary completion point of 4 weeks were analyzed.ResultsA total of 87 participants (mean [SD] age, 67.1 [6.7] years; 47 [54.0%] female) were randomized to standard bilateral rTMS and 85 (mean [SD] age, 66.3 [5.3] years; 45 [52.9%] female) to TBS, of whom 85 (98%) and 79 (93%) were assessed for the primary outcome, respectively, whereas tolerability was assessed in all randomized participants. In the rTMS group, 4 (4.6%) were American Indian, reported other, or preferred not to answer; 5 (5.8%) were Asian; and 78 (89.7%) were White. In the TBS group, 6 (7.1%) were Asian, 2 (2.4%) were Black or reported other, and 77 (90.3%) were White. Mean (SD) Montgomery-Åsberg Depression Rating Scale total scores improved from 25.6 (4.0) to 17.3 (8.9) for rTMS and 25.7 (4.7) to 15.8 (9.1) for TBS (adjusted difference, 1.55; lower 95% CI −0.67), establishing noninferiority for TBS. The all-cause dropout rates were relatively similar between groups (rTMS: 2 of 87 [2.3%]; TBS: 6 of 85 [7.1%]; P = .14; χ2 = 2.2).Conclusions and RelevanceIn older adults with TRD, bilateral TBS compared with standard bilateral rTMS achieved noninferior reduction in depression symptoms. Both treatments had low and similar dropout rates. Using TBS rather than rTMS could increase access to treatment several-fold for older adults with TRD.Trial RegistrationClinicalTrials.gov Identifier: NCT02998580

Purpose: It has been observed that certain patients with chronic spontaneous or idiopathic urticaria (CSU/ CIU) have a personal history of a significant stressor before urticaria onset, while the prevalence of any psychopathology among these patients is significantly higher than in healthy individuals. Research has confirmed that skin is both an immediate stress perceiver and a target of stress responses. These complex interactions between stress, skin, and the nervous system may contribute to the onset of chronic urticaria. This systematic review investigated the association between CSU/CIU and neuroimmune inflammation with or without evidence of co-existing psychological stress from in vivo and ex vivo studies in human beings. Methods: PubMed and Scopus were searched to September 2019 for reports in human beings describing neuroimmune inflammation, stress, and CSU/CIU. A comprehensive search strategy was used that included all the relevant synonyms for the central concept. Findings: A total of 674 potentially relevant articles were identified. Only 13 satisfied the predefined inclusion criteria and were included in the systematic review. Five of these 13 studies evaluated the correlation between CSU/CIU, stress, and neuroimmune-cutaneous factors, while the remaining 8 focused on the association between CSU/CIU and these factors without examining any evidence of stress. Implications: The complex neuro-immunecutaneous model that involves numerous neuropeptides and neurokinins, inflammatory mediators and cells, hypothalamic-pituitary-adrenal axis hormones, and the skin may better explain the underlying pathophysiological mechanisms involved in the onset of urticaria. In addition, the elevated psychological stress level that has been closely related to CSU/CIU could be attributed to the imbalance or irregularity of this neuro-immune-cutaneous circuit. It is still unclear and must be further investigated whether any psychological stress results in or triggers CSU/CIU onset on top of a preexisting neuroimmune dysregulation. Nevertheless, new psycho-phenotypic or neuro-endotypic CSU/CIU subsets should be considered as the era of personalized treatment strategies emerges. A better understanding of CSU/ CIU pathophysiology and consideration of the patient as a whole is vital for identifying targets for new potential treatment options (Clin Ther.