BackgroundMild Cognitive Impairment (MCI) and Mild Behavioral Impairment (MBI) can be prodromal stages of neurodegenerative disease associated with plasma biomarkers of tau pathology and neuroaxonal damage. However, in psychiatric populations, the relationship between MCI, MBI and these plasma biomarkers remains unclear.ObjectiveThis study examined the association of MCI with plasma biomarkers of neurodegeneration (phosphorylated tau217 [p-tau217] and neurofilament light chain [NfL]), metabolic alterations, psychiatric disorder features, and MBI in older adults receiving psychiatric treatment.MethodsFifty-one non-demented patients ≥60 years, referred for mood or anxiety disorders, were enrolled and classified based on cognitive performance as MCI (n = 20) or non-MCI (n = 31). Assessments included psychiatric, cognitive, functional, and plasma biomarker measures.ResultsMCI patients exhibited higher p-tau217 (P = .003) and NfL (P = .042) levels, lower cognitive scores (P < .001), and a trend toward reduced functioning (P = .074). MCI was also associated with later onset of psychiatric symptoms (P = .033) and greater prevalence of MBI (P < .001). Logistic regression identified plasma NfL as a marker of MCI (P < .05) in this sample.ConclusionOur findings suggest that integrating cognitive, psychiatric, and biomarker assessments may improve early detection of dementia risk.

Attention-deficit/hyperactivity disorder (ADHD) and borderline personality disorder (BPD) frequently co-occur. However, evidence on the clinical effects of stimulant treatment in ADHD-BPD comorbidity remains limited. This prospective study aimed to investigate the longitudinal effects of methylphenidate (MPH) on borderline personality features in adults with ADHD-BPD. Thirty-six adults diagnosed with ADHD who also met the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition criteria for BPD were treated with MPH and followed for at least 16 weeks. Clinical ratings of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition BPD criteria and psychometric measures assessing symptom severity and personality functioning were obtained at baseline and follow-up. Twenty-four participants (66.7%) completed the follow-up. Follow-up duration ranged from 3.9 to 12.3 months, with a mean duration of 7.8 ± 2.48 months. The number of BPD criteria significantly decreased after treatment ( r  = 0.82, P  < 0.001). Nineteen participants no longer met the diagnostic threshold for BPD, and 10 achieved remission (≤2 BPD criteria). Baseline anger dysregulation ( P  = 0.009) and mood stabilizer use ( P  = 0.029) were associated with continued MPH treatment. Our findings preliminarily suggest that MPH, especially combined with mood stabilizers, may be associated with clinical benefits and acceptable tolerability in patients with comorbid ADHD-BPD. While causal conclusions cannot be drawn, replication in randomized controlled trials is warranted.

The Adult Executive Functioning Inventory (ADEXI) is a brief novel self-report questionnaire designed to assess executive functioning. The aim of this study was to evaluate the psychometric properties of its Italian version in adults with attention-deficit/hyperactivity disorder (ADHD). A clinical sample of 84 adults diagnosed with ADHD at a tertiary care center was recruited. Discriminant validity was examined with respect to 252 age- and sex-matched non-clinical controls and norms extracted from a large epidemiological survey. Good internal consistency was observed for both the total score (Cronbach's α = 0.857) and subscale scores (α = 0.731-0.825). Both one- and two-factor structures showed acceptable fit. Convergent validity was supported by moderate correlations with self-reported ADHD symptoms measured by the ASRS-v1.1 Part A (r = 0.422-0.502), while only weak correlations were found with informant-reported executive impairments on the BRIEF-A (r = 0.231-0.237). Significant differences between participants with ADHD and non-clinical controls were observed. ADEXI total score best identified participants with ADHD using a cutoff ≥ 34, with accuracy = 89.6%, sensitivity = 92.9%, and specificity = 88.5%. ADEXI total scores converted in T-scores based on normative data revealed a prevalence of at least mild executive impairment (T-score ≥ 60) of 86.9% in the clinical sample, while two-thirds showed severe executive impairment (T-score ≥ 70; 66.7%). In conclusion, the ADEXI could be considered a useful instrument to screen for executive functioning impairments among the general population and a promising tool to stratify the severity of self-reported executive impairment across different clinical samples.

Background/Objectives: Sex differences in adult attention-deficit/hyperactivity disorder (ADHD) remain insufficiently characterized, particularly in clinically referred samples assessed through multidimensional and multi-informant approaches. This study investigated sex differences in clinical presentation, psychiatric comorbidity, psychometric features, and ADHD severity in adults with ADHD, with a specific focus on emotional dysregulation and rating-source effects. Methods: A total of 212 consecutively recruited adults with ADHD, including 93 females and 119 males, underwent a comprehensive assessment at a tertiary referral service. Sex differences were examined across sociodemographic, clinical, comorbidity, functional, and psychometric domains. ADHD severity was assessed using both self-rated and observer-rated measures. Regression, mediation, and repeated-measures mixed-effects models were fitted to examine the role of emotional dysregulation in the association between sex and ADHD severity. Results: Females showed a higher frequency of predominantly inattentive presentation; higher rates of mood, anxiety, and eating disorders; and more pronounced emotional dysregulation, affective temperamental traits, personality-related impairment, and biological rhythm disturbances. Observer-rated ADHD severity did not differ by sex, while females reported higher self-rated ADHD severity. Emotional dysregulation was associated with both observer-rated and self-rated ADHD severity, with a stronger association for self-rated symptoms. Mediation analysis showed a significant indirect effect of female sex on self-reported ADHD severity through emotional dysregulation, accounting for 79.4% of the total association. Mixed-effects models further indicated that sex differences in ADHD severity varied according to rating source and persisted, although attenuated, after accounting for emotional dysregulation. Conclusions: Adult females with ADHD showed a different clinical profile, characterized by greater internalizing comorbidity, emotional dysregulation, personality-related impairment, and biological rhythm disturbances. Emotional dysregulation accounted for a substantial part of the higher self-reported ADHD severity observed among females, while rating-source effects suggested that sex differences in adult ADHD may partly depend on how symptom severity is assessed.

Background/Objectives: Adolescents with attention-deficit/hyperactivity disorder (ADHD) and bipolar spectrum disorders are at increased risk of substance use; categorical diagnoses may not fully explain individual variability in substance-related outcomes. This study examined substance use severity in clinically complex adolescents, focusing on the role of primary diagnosis and transdiagnostic dimensions (emotional dysregulation, impulsivity, cyclothymic-hypersensitive traits). Methods: In this cross-sectional observational study, 47 adolescents (aged 14-17) with DSM-5 diagnoses of ADHD or bipolar spectrum disorders were recruited from two Italian child and adolescent mental health services. Substance use severity was assessed using the Q-PAD Substance Abuse scale and the ABQ. Emotional dysregulation, impulsivity, affective temperament, and emotional-behavioral problems were assessed through RIPOST-Y, BIS-11, CHT-Q, and YSR. Correlation studies and group comparisons based on the Q-PAD Substance Abuse scale were performed to explore associations between clinical features and substance use. Results: Substance use severity was elevated in the overall sample and was not significantly associated with primary diagnostic category, overall illness severity, or global functioning. Higher Q-PAD Substance Abuse scores were significantly associated with impulsivity, emotional dysregulation, and hypersensitivity traits. Later initiation of lithium treatment was also associated with greater substance use severity. Conclusions: In this sample, substance use severity was more related to dimensional transdiagnostic vulnerabilities than to categorical diagnosis. Although preliminary and exploratory, these findings support early identification and targeted intervention on emotional dysregulation and impulsivity as potentially modifiable risk factors for adolescent substance use.

Psychiatric symptoms are frequently found in patients with cancer and often require specific pharmacological treatment. Depression seems to be the most common psychiatric disorder followed by adjustment disorders, anxiety, and delirium. Psychiatric comorbidities are responsible for worse quality of life and low adherence to anticancer treatment. Many different psychiatric drugs are beneficial, but there are increasing risks of drug–drug interactions (DDIs) with anticancer drugs. We conducted a PRISMA-compliant systematic review (PROSPERO registered) on drug–drug interactions between psychiatric and anticancer medications, using predefined search terms in electronic databases and specialized interaction software. Only six studies met the predefined inclusion criteria, confirming a significant lack of evidence on this topic. The available studies were often limited by small sample sizes, inadequate controls, or insufficient assessment of drug interactions. Our expanded search in drug interaction software allowed us to cross-reference results and identify clinically relevant interactions. The aim of this paper is to collect and summarize in a user-friendly format the most significant DDIs and to show unfavorable and potentially dangerous combination of drugs.

Emotional dysregulation (ED) reflects a heightened reactivity to stimuli, characterized by excessive negative affect and impulsive behaviors. This study aimed to evaluate ED in workers seeking care for occupational stress and to examine its associations with sociodemographic characteristics, occupational stress, and the severity of anxiety and depressive symptoms. Eighty-seven workers referred for work-related stress were assessed using the Psychological Stress Measure (PSM) and the Job Content Questionnaire (JCQ) for stress, the Beck Depression Inventory-II (BDI-II) and the Self-Rating Anxiety Scale (SAS) for psychopathology, and the RIPoSt-40 for ED. Group comparisons and correlation analyses were conducted using parametric or non-parametric tests, as appropriate. Forty-six percent of participants met criteria for Adjustment Disorders and 54% for Major Depressive Disorder. No significant differences between diagnostic groups emerged for ED or symptom severity. Women reported higher perceived stress and anxiety than men. Negative ED domains-affective instability, negative emotionality, and emotional impulsivity-showed moderate-to-strong positive correlations with stress, anxiety, and depressive symptoms. Affective instability was also related to job stress dimensions, correlating negatively with decision latitude and positively with job demands. Negative emotional dysregulation appears to be a transdiagnostic vulnerability factor for stress-related psychopathology. Screening for ED may support early detection and targeted preventive interventions in occupational settings.

Objectives: Mixed depression remains poorly operationalised in current nosologies, leading to misclassification and suboptimal treatment. We propose a two-subtype framework—Bipolar-Expansive Depression (BXD) and Unspecific-Excitative Depression (UXD)—to improve recognition and guide safer treatment choices. Methods: Narrative synthesis of historical accounts, critiques of DSM-5 and ICD-11, Koukopoulos’ concepts, the ISBD Task Force report (2022), validation of the Shahin Mixed Depression Scale (SMDS), and introduction of the Shahin Activated Depression Screener (SADS). Results: BXD combines depressive mood with expansive/energised features (pressured speech, goal-directed bursts, racing thoughts, reduced need for sleep). UXD presents depressive mood with excitatory distress (agitation, irritability, inner tension, motor restlessness, mood lability, crowded/racing thoughts). SMDS has been validated for non-DSM excitatory features. SADS is under development and has not yet been validated. Conclusions: Recognising BXD and UXD refines the concept of mixed depression, addressing DSM-5/ICD-11 gaps and improving patient care

OBJECTIVE:The present study aims to provide a detailed clinical characterization of adult patients with bipolar disorder (BD) and comorbid autism spectrum disorder without intellectual disability (ASD-noID), through a comparison with a control group of individuals with BD only. METHODS:We conducted a cross-sectional observational study involving 62 adults with comorbid BD and ASD-noID, recruited at the University Hospital of Pisa between June 2022 and April 2023. Clinical history, psychiatric diagnoses, and symptom profiles were collected using standardized assessment procedures. Group comparisons with a sex-matched control sample of BD patients without ASD were performed. RESULTS:Patients with ASD-BD exhibited an earlier onset of mood symptoms, a higher prevalence of other specified bipolar and related disorder (BD-OS) diagnoses, and greater rates of comorbid anxiety disorders. Temperamental assessment revealed significantly higher scores in cyclothymic, anxious, and depressive dimensions. The ASD-BD group also reported lower global functioning. Finally, ASD-BD individuals show high frequency of adverse reactions to antidepressants and antipsychotics. CONCLUSIONS:BD in adults with ASD-noID presents a distinct clinical phenotype, characterized by atypical mood presentations, emotional dysregulation, complex comorbidity, and reduced treatment tolerability. These findings highlight the importance of improving diagnostic accuracy and adopting personalized treatment approaches for adults with this comorbidity.

ABSTRACT:Frontotemporal dementia (FTD) encompasses a group of clinically, neuropathologically, and genetically heterogeneous disorders characterized by atrophy in the frontal and anterior temporal lobes. Psychiatric and behavioral symptoms are common throughout the course of FTD, and pharmacological treatments show limited efficacy. In this review, we analyzed literature on the use of electroconvulsive therapy (ECT) in patients with FTD to assess its effectiveness and predictors of response in this population. A systematic review was conducted following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines, with searches in the MEDLINE, Scopus, and Web of Science databases. Eligibility criteria included original studies and case reports on FTD patients treated with ECT. Of 88 screened abstracts, 25 studies were included, documenting 37 patients with FTD or Pick disease who were treated with ECT. ECT was primarily administered for catatonia (37.84%) and depressive episodes (35.14%). Most patients had not responded to at least 1 prior medication, primarily antipsychotics. Following the initial ECT course, 40.54% of patients experienced symptom remission, 21.62% showed partial or transient improvement, and 32.43% saw little to no benefit. Continuation and maintenance ECT appeared to be valid treatment options following a response to acute ECT. Notably, patients with the C9orf72 mutation showed a poor response to ECT. For many FTD patients with behavioral, mood, and catatonic symptoms, ECT appears to be more effective than pharmacological treatments; however, its impact on cognition and long-term outcomes requires further investigation. Systematic clinical studies on larger samples are necessary to confirm the efficacy and tolerability of ECT for psychiatric disorders in FTD.

Background: Attention-Deficit/Hyperactivity Disorder (ADHD) in adulthood is frequently associated with complex psychiatric comorbidity, including high rates of Substance Use Disorders (SUDs), which may influence treatment outcomes. Although pharmacological treatments are effective for core ADHD symptoms, real-world response remains heterogeneous, and the contribution of specific substance-related and neurodevelopmental factors to treatment response is not fully understood. Methods: This retrospective observational study examined a real-world cohort of 67 adults with ADHD treated pharmacologically in a specialized outpatient setting. ADHD was diagnosed according to DSM-5-TR criteria using the Diagnostic Interview for ADHD in Adults (DIVA-5). Autism spectrum disorder (ASD) was recorded based on documented pre-existing specialist diagnoses and confirmed clinically at baseline. Psychiatric comorbidities and substance use disorders, including alcohol and cannabis use disorders, were assessed according to DSM-5-TR criteria. Clinical response was defined using the Clinical Global Impression-Improvement scale (CGI-I; responders = scores 1-3). Exploratory binary logistic regression analyses were used to identify clinical factors associated with treatment response. Given the limited sample size, revised multivariable models were specified parsimoniously on the basis of a priori clinical relevance. Results: At follow-up, 48 of 67 patients (71.6%) met criteria for clinical response. In revised parsimonious multivariable models, alcohol use disorder (OR ≈ 0.08-0.10, p = 0.010-0.026) and cannabis use disorder (OR ≈ 0.20-0.24, p = 0.014-0.028) were consistently associated with reduced odds of clinical response. Autism spectrum disorder showed a descriptive trend toward lower response rates but did not retain statistical significance after adjustment (p ≈ 0.11-0.15). Conclusions: In adults with ADHD treated in routine clinical practice, alcohol and cannabis use disorders were associated with a reduced likelihood of achieving clinically meaningful improvement under routine pharmacological care, whereas autism spectrum disorder showed a trend toward lower response that was not stable enough to support firm conclusions. These findings should be considered exploratory given the retrospective design, limited sample size, and lack of systematic treatment exposure measures.

Background: The association between emotional dysregulation (ED) and attention-deficit/hyperactivity disorder (ADHD) has been widely documented. However, a consensus has yet to be reached on how to conceptualize this domain within ADHD. Particularly, ADHD + ED may represent a distinct condition, a more severe ADHD, or a comorbidity. We explored these three main hypotheses, investigating clinical differences between patients with ADHD, ADHD + ED, and ED. Methods: In total, 101 participants (ages 18–50) were recruited and divided into four groups: ADHD (N = 23), ED (N = 28), ADHD + ED (N = 27), and HC (N = 23). ADHD and ED were assessed using the Diagnostic Interview for ADHD in adults (DIVA-5) and the Wender–Reimherr Adult Attention Deficit Disorder Scale (WRAADDS). Sociodemographic and clinical variables were compared among the groups. Results: Participants with ADHD and ADHD + ED exhibited comparably high ADHD severity and executive dysfunction ratings. While participants with ADHD + ED shared elevated negative emotionality and higher rates of mood disorders and anxiety disorders with participants with ED compared with those with ADHD, they showed specifically increased developmental and disruptive comorbidities, as well as earlier onset and greater cyclicity of comorbid mood disorders. Psychosocial functional impairments were similarly elevated on average in ADHD + ED and ADHD, but ADHD + ED showed more pronounced and widespread deficits across multiple domains. Conclusions: ADHD + ED is unlikely to represent a more severe form of ADHD but may be more appropriately conceptualized as either a distinct entity or a “comorbid” phenotype. Comparisons with ED without ADHD highlighted clinical features specific to ADHD + ED, including a higher neurodevelopmental load, impulse-control disorders, and a poorer course of mood disorders.

Background: Bariatric surgery is the most effective long-term treatment for severe obesity; however, a subset of patients fails to achieve optimal weight loss. This study investigated the role of psychiatric disorders and transdiagnostic psychopathological traits in predicting weight loss outcomes two years after surgery. Methods: This prospective naturalistic study included 125 consecutive bariatric surgery candidates undergoing routine preoperative psychiatric assessment. Psychiatric comorbidities, emotional dysregulation and ADHD-related dimensions were assessed using structured clinical interviews and self-report questionnaires. Weight outcomes were evaluated at 24 months after bariatric surgery, with post-surgical inadequate weight loss defined as percentage of excess weight loss (%EWL) < 50%. Results: Of the 125 patients initially assessed, 89 underwent bariatric surgery and 48 completed the follow-up. At 24 months, 10 patients (20.8%) showed inadequate weight loss. Poorer weight outcomes were associated with older age, sleeve gastrectomy, and lifetime mood disorders, whereas no significant associations emerged with anxiety disorders or binge eating disorder. Patients with inadequate weight loss showed higher levels of emotional dysregulation, while no differences emerged for other ADHD-related dimensions. Emotional dysregulation remained significantly associated with poorer weight outcomes in multivariate analysis. Conclusions: Emotional dysregulation may represent a transdiagnostic factor influencing bariatric surgery outcomes, supporting the importance of integrating emotional and cognitive dimensions into preoperative assessment and postoperative care.

Autoimmune encephalitis (AE) tends to manifest as a mixture of neuropsychiatric and somatic symptoms, either of which may predominate, and often shows a progressive clinical course sometimes leading to life-threatening conditions. Catatonic and psychotic syndromes, regardless of whether associated with dysautonomia, are common manifestations of AE, especially concerning the anti-NMDAR subtype. Several autoantibodies targeting different neuronal epitopes have been linked to specific clinical manifestations and their detection is embedded in some of the diagnostic criteria for AE. Therapeutical management of AE is challenged by limited diagnostic abilities and poor understanding of the underlying pathophysiology for most of its subtypes. Although the prompt delivery of disease-modifying therapies represents the cornerstone of treatment and primarily affects prognosis, less is known about the role of symptom specific supportive measures like electroconvulsive therapy (ECT). Based on a systematic review of 26 patient-level descriptions of individuals, each with a diagnosis of AE treated with ECT, a favorable clinical response was found in more than 3/4 of the revised cases (76.9%). The most common indications for ECT administration were catatonic and psychotic syndromes, often nonresponsive to prior pharmacotherapy with benzodiazepines, antipsychotic, and other psychotropic drugs. Noteworthy side effects were only reported for 3 of 26 patients. Though the low number of cases and publication bias should be considered as major limitations, current available reports are in support of the inclusion of ECT in the integrated therapeutic algorithm of AE to address psychiatric conditions such as severe psychosis and catatonia.

INTRODUCTION:After a long period of obscurantism, a possible role of psychedelics in clinical practice has progressively become a tangible perspective during the last two decades. However, the resounding enthusiasm linked to such 'psychedelic renaissance' runs the risk to unduly minimize the possible hazards associated with these compounds, while expanding their alleged benefits to improbable panacea-like proportions. In order to avoid mystifying or demonizing the properties of 5-HT2a agonists on emotional grounds, this subject requires a strictly unprejudiced and cautious approach to the evidence. AREAS COVERED:In this article, the authors attempted to comprehensively analyze the available literature to provide a balanced overview of the possible benefits of psychedelics in healthcare, taking into account their potential risks. EXPERT OPINION:To date, psychedelics have shown a therapeutic potential in a wide range of conditions, with a seemingly limited risk of inducing adverse reactions, including abuse and dependence, when administered in a controlled environment by specialized personnel. In any case, although several questions remain unanswered before drawing firm conclusions, further studies are needed to establish which conditions and subjects could benefit from psychedelics and which patients bear the greater risk of adversities.

BACKGROUND:Affective temperaments predispose to life adaptation and affective disorders. The relationship between temperaments and sleep quality is rarely investigated in community-based studies. We hypothesized that cyclothymic-related temperaments relate to worse sleep quality, whereas the hyperthymic temperament favours sleep quality. METHOD:We investigated 3701 18 to 65 years old adults from the population-based CHRIS study in Italy. Participants were 54 % females, mean age 38.5 years. The Pittsburgh Sleep Quality Index (PSQI) was the primary outcome score. Five affective temperaments split into quartiles for direct comparison from the TEMPS-M questionnaire were the exposures of interest. Additional covariates comprised sex, age, trait anxiety, and sleep quality-related lifestyles assessed via interviews, self-administered questionnaires or instrumental measurements. RESULTS:The hyperthymic temperament showed a negative association (better sleep quality) with the global PSQI, whereas the cyclothymic-related temperaments had all associations in opposite direction. While inclusion of trait anxiety appeared to mediate some results, the anxious and other cyclothymic related temperaments were still directly associated with multiple dimensions of poor sleep quality. LIMITATIONS:The cross-sectional design, possible selection into the study by temperamental background or sleep disorders, and no clinically validated self-assessed psychiatric constructs represent possible weaknesses. CONCLUSIONS:Our findings support the hypothesis of a biological binary diathesis of affective temperaments, with hyperthymic and cyclothymic-related temperaments predisposing sleep quality in an antithetical way.

Emotion dysregulation (ED), a core feature of Bipolar Disorder (BD), contributes to symptom severity, mood instability, and reduced quality of life. Emerging evidence suggests that interoception-the ability to perceive and integrate internal bodily signals-may play a pivotal role in shaping emotional experience. However, the relationship between interoceptive sensibility and ED in BD remains poorly understood. This study investigated whether interoceptive sensibility mediates ED in individuals with Bipolar II Disorder during a depressive episode (BD2-D). Sixty inpatients with BD2-D and 36 healthy controls completed a psychometric assessment including the Difficulties in Emotion Regulation Scale (DERS), the Multidimensional Assessment of Interoceptive Awareness (MAIA), the Beck Depression Inventory-II (BDI-II), and the Self-Rating Anxiety Scale (SAS). Compared to controls, patients exhibited significantly higher ED across all DERS components (p-value <0.01), and lower interoceptive sensibility, both in total scores and in six of eight MAIA components (p < 0.005). Partial correlations showed strong negative associations between interoceptive sensibility and ED, particularly in self-regulation and trust in bodily signals. Mediation analysis indicated that interoceptive sensibility significantly mediated the relationship between BD2-D and ED (indirect effect β = 16.18, 95 % CI [8.54, 27.54]). These findings highlight the pivotal role of interoceptive sensibility in emotional regulation in BD2-D. Impaired integration of bodily signals may jeopardize self-regulation and increase emotional vulnerability. Interoception may therefore represent a promising target for intervention in mood disorders.

According to international guidelines, lithium treatment represents the gold standard for the appropriate management of persons with bipolar disorder. However, prescription rates in ordinary practice are not in line with clinical guidelines’ suggestions. Clinicians prefer to use drugs other than lithium, considering its low therapeutic window, the need for regular lab tests and its side effects profile. Based on these premises, a Delphi-method study focused on highly-debated aspects of lithium treatment in bipolar disorder has been promoted with the aim to reach a consensus among an expert panel of Italian psychiatrists. The Delphi method is a structured technique aimed to obtain a consensus from repeated rounds of questionnaires where opinion/agreement among experts are important. A Steering Committee of experts has developed a 24-items questionnaire exploring: (1) the use of lithium as first choice for treating different phases of bipolar disorder; (2) the side effect and tolerability profile of lithium treatment as hampering factors for its use in clinical practice; (3) the lithium prescribing in special target population, such as adolescents, elderly patients, and pregnant women. The questionnaire was delivered to a panel of 100 Italian psychiatrists, experts in the field of managing people with bipolar disorders. An almost complete positive consensus was reached for statements dealing with the use of lithium treatment as first choice in the management of patients with bipolar disorder, and as the first choice for preventing manic/hypomanic and depressive episodes. Current clinical guidelines and scientific evidence support the use of lithium as first choice treatment in patients with bipolar disorder. However, over the last decades a downward tendency in lithium’s prescription has been registered worldwide. The present Delphi study confirmed the “good clinical reasons” for supporting lithium prescription in clinical practice. Our findings should be used to develop clinical practice guidelines and reduce the discrepancy between international guidelines and ordinary care.

INTRODUCTION:The prescription of psychotropic drugs during pregnancy is a constantly increasing practice, but its safety information remains limited. On the other side, while concerns about teratogenicity persist, it is also evident that mothers' psychiatric disorders represent a risk factor for both them and the infants and cannot be neglected or left untreated. Therefore, careful monitoring and dose adjustments are essential to minimize risks while ensuring treatment efficacy. AREAS COVERED:The present article is a narrative review of the literature on psychotropic drug use in pregnancy and lactation, attempting to summarize their benefits and risks while considering maternal and fetal outcomes. EXPERT OPINION:Whenever possible, medications should be avoided in the first trimester, with the lowest effective dose used throughout pregnancy. In severe cases, drugs cannot be stopped as discontinuation can lead to relapse, but they require individualized risk-benefit assessments. For lactating mothers, drugs with established safety profiles should be prioritized. Further research is needed to clarify long-term effects and support evidence-based decisions in maternal mental health care.