Living With Bipolar Disorder in the Time of Covid-19: Biorhythms During the Severe Lockdown in Cagliari, Italy, and the Moderate Lockdown in Tunis, Tunisia

The Inaccuracy of the Mood Disorder Questionnaire for Bipolar Disorder in a Community Sample: From the "DYMERS" Construct Toward a New Instrument for Detecting Vulnerable Conditions

Background/Objectives: The Mood Disorder Questionnaire (MDQ) is a widely used tool for the early detection of Bipolar Disorder (BD), yet its diagnostic accuracy remains debated. In particular, the MDQ often yields false positives in individuals with anxiety, stress-related, or personality disorders, raising questions about its clinical utility. This study aimed primarily to evaluate the sensitivity, specificity, and predictive values of the MDQ in identifying BD within a large, community-based sample using structured clinical interviews. Additionally, we explored the construct of DYMERS (Dysregulation of Mood, Energy, and Social Rhythms Syndrome), a proposed condition characterized by mood instability, hyperactivation traits, and rhythm dysregulation among MDQ-positive individuals without a formal psychiatric diagnosis. Methods: A total of 4999 adults were surveyed across six Italian regions using a stratified random sampling method. Psychiatric diagnoses were established using DSM-IV-TR criteria via the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS). The MDQ was administered face to face in its validated Italian version, with a positivity cut-off of ≥7. The MDQ exhibited low sensitivity and high specificity (0.962; 95% CI: 0.961-0.963). Results: Among 2337 analyzable cases, the MDQ showed high specificity (96.2%) but low sensitivity (42.9%) for BD, indicating limited effectiveness as a screening tool. In clinical terms, this implies that while MDQ-positive individuals are unlikely to be false positives, a substantial proportion of true BD cases are not identified. Notably, a significant subgroup of MDQ-positive individuals without psychiatric diagnoses displayed features consistent with DYMERS. Conclusions: Our findings confirm the limited screening value of the MDQ for BD in community samples. However, MDQ positivity may help identify a broader spectrum of mood and rhythm dysregulation not captured by current diagnostic systems. Future research should focus on validating DYMERS as a clinical entity and on developing targeted diagnostic instruments capable of capturing this emerging dimension of psychopathology.

An Integrated Cognitive Remediation and Recovery-Oriented Program for Individuals with Bipolar Disorder Using a Virtual Reality-Based Intervention: 6- and 12-Month Cognitive Outcomes from a Randomized Feasibility Trial

INTRODUCTION

Achieving long-term impacts from cognitive remediation (CR) interventions is a key goal in rehabilitative care. Integrating virtual reality (VR) with psychoeducational approaches within CR programs has shown promise in enhancing user engagement and addressing the complex needs of individuals with bipolar disorder (BD). A previous randomized controlled crossover feasibility trial demonstrated the viability of a fully immersive VR-CR intervention for BD, reporting low dropout rates, high acceptability, and significant cognitive improvements. This secondary analysis aimed to evaluate the stability of these outcomes over time.

METHODS

This paper presents a 6- to 12-month follow-up of the initial trial. Secondary cognitive outcomes were assessed, including visuospatial abilities, memory, attention, verbal fluency, and executive function, using validated assessment tools. Statistical analyses were conducted using Friedman's test.

RESULTS

A total of 36 participants completed the 6- to 12-month follow-up. Overall, cognitive functions showed a trend toward stability or improvement over time, except for visuospatial and executive functions, which demonstrated inconsistent trajectories. Significant improvements were observed in language (p = 0.02).

CONCLUSION

This study highlights the overall stability of cognitive functions 12 months after a fully immersive VR-CR program for individuals with BD. To sustain long-term clinical benefits, an integrated approach, such as incorporating psychoeducational strategies within cognitive remediation interventions, may be essential. Further follow-up studies with control groups and larger sample sizes are needed to validate these findings.

The Breathomics Profile of Volatile Sulfur Compounds in the Bipolar Spectrum, Does It Represent a Potential Tool for Early Diagnosis?

Background/Objectives: Emerging laboratory technologies, such as breathomics, may enhance the early diagnosis of psychiatric disorders, including Bipolar Disorder (BD). This study investigates the detection of volatile sulfur compounds (VSCs) in exhaled breath as potential biomarkers for BD, comparing VSC levels between individuals with BD, healthy controls, and individuals with non-pathological hyperactivity. Methods: A matched case-control study was conducted involving 24 patients with BD and 95 healthy controls recruited at the University Hospital of Cagliari. Controls were selected using a matched-pair design based on age (±5 years) and sex through a block-matching technique to ensure comparability with cases. Participants underwent psychiatric interviews, completed the Mood Disorder Questionnaire (MDQ), and had their exhaled breaths analyzed for VSCs using a gas chromatograph (OralChroma™). Controls were selected and randomized for age and sex. Results: Patients with BD exhibited significantly higher levels of methyl mercaptan (CH3SH) compared to healthy controls (18.62 ± 5.04 vs. 9.45 ± 18.64 ppb, p = 0.022). Among individuals without BD, those with positive MDQ scores showed lower levels of CH3SH than those with negative scores (9.17 ± 5.42 vs. 15.05 ± 18.03); however, this difference did not reach statistical significance (p = 0.254), highlighting how the deep connection between some clinical and laboratory aspects needs to be investigated more thoroughly. Conclusions: The results suggest a correlation between oral dysbiosis and metabolic alterations in patients with BD, with CH3SH levels being higher in cases compared to controls. Further studies are needed to validate the use of VSCs as potential biomarkers for BD and to investigate their role in individuals with non-pathological hyperactivity.

Impact of Pre-lockdown Hyper-energy on Mood and Rhythm Dysregulation in Older Adults During the COVID-19 Pandemic

Objective

The aim of this work is to verify whether a cohort of elderly people with hyper-energy tended to increase depressive symptoms and misaligned social and personal rhythms during the lockdown compared to a cohort of older adults without hyper-energy one year before the lockdown.

Methods

The two cohorts were evaluated in April 2019 (T0) and in April 2020 (T1). Hyper-energy, cognitive performance, depressive symptoms, and social and personal rhythms were evaluated at T0 and T1.

Results

In the measure of the Brief Social Rhythm Scale (BSRS) score, the differences between groups in the two observation times reach statistical significance. The sub-group with previous hyper-energy at T0 but no longer having hyper-energy at T1 increases the score by more than 5 points (a higher score indicates greater rhythm dysregulation, thus having a worse regulation of rhythms at T1), while in those individuals who didn't have hyper-energy, the score remains substantially unchanged (+0.06). However, if the increase in the score from T0 and T1 is measured, both groups with hyper-energy at T0 presented a greater mean increase compared to people who did not have hyper-energy at T1. In the total of the eleven elderly people with hyper-energy at T0, the mean increase in BSRS score was 1.05±1.19 versus 0.06±0.98 (F=9.407, P=0.003), and in people who no longer had hyper-energy at T1, it was 1.05±1.19 versus 5.50±3.83 (F=105.0, P<0.0001). In people with hyper-energy at T0, the mean increase in the Patient Health Questionnaire-9 (PHQ-9) score was 0.72±0.75 versus 0.01±0.28 (F=37.153, P<0.0001). The gain was even higher in people who no longer had hyper-energy at T1, 1.38±1.03 vs. 0.01±0.28 (F=87.386, P<0.0001). An inverse linear correlation was found between energy perception (measured as the score of Item 10 of SF-12) and the score of PHQ-9 measuring depressive symptoms both at T0 and, more strongly, at T1, as well as with the BSRS scores, but only at T1.

Conclusion

The study, despite the limitations of a small sample, seems to confirm a greater vulnerability to the lockdown situation in people with hyperactivity, even in the absence of psychopathology (i.e., part of the bipolar spectrum).

An Initial Scoping Review of Dysregulation of Mood, Energy, and Social Rhythms Syndrome (DYMERS) Regarding Burnout in Healthcare Professionals During COVID-19

Background/Objectives: Dysregulation of Mood, Energy, and Social Rhythms Syndrome (DYMERS) characterizes the poor regulation of biological (sleep/waking), social, and behavioral rhythms that affected the level of burnout in healthcare professionals during the pandemic in particular. The aim is to provide an initial scoping review of publications on this topic. Methods: The keywords "Stress Rhythms Dysregulation Bipolar Disorder Burnout DYMERS Healthcare professionals COVID-19" were searched on 9 December 2024 following PRISMA 2020 guidelines, using five primary databases (OVID, ProQuest, PubMed, Scopus, Web of Science), one register (Cochrane COVID-19 register), and one supplementary database (Google Scholar). Included were peer-reviewed publications. Excluded were duplicates, reports lacking either a research study or any keywords, or including irrelevant information regarding them. Results: The returns for all the databases were (n = 0) except for ProQuest (n = 4) and Google Scholar (n = 14). Of these, three ProQuest returns were duplicates of the Google Scholar search. The remaining report contained irrelevant information on healthcare professionals. The Google Scholar search results produced two relevant reports-neither duplicated with ProQuest. The excluded contained a duplicate in the search itself, three that did not mention healthcare professionals, two that contained irrelevant information concerning them, four returns that were not a research study, and three that were not peer-reviewed. Conclusions: The two studies published on this topic are by various members of the same investigating institution. DYMERS has provided valuable insights regarding burnout in healthcare professionals. The suggestion is for further DYMERS research by this team and others, anticipating future pandemics.

Adaptive Hyperactivity and Biomarker Exploration: Insights from Elders in the Blue Zone of Sardinia

Background/Objectives: Adaptive hyperactivity characterized by increased activity levels and novelty-seeking traits without mood disorders is prevalent among older adults in Sardinia's "blue zone," an area with high longevity. This study aims to evaluate the adaptive nature of hyperactivity concerning quality of life, social rhythms, and mood symptoms in individuals from this region, particularly among elderly adults over 80. Methods: This observational cross-sectional study included adults and older adults over 80 from Sardinia's blue zone. This study included a sample of patients followed at the Center for Consultation Psychiatry and Psychosomatics for Bipolar Disorder of the University Hospital of Cagliari and a homogeneous comparison sample of patients without psychiatric pathologies, referred to the Dermatology Clinic of the same hospital, for a period of 6 months, from February to August 2024. The general sample, divided into two parts-cases, represented by patients with psychiatric pathology, and controls, patients without psychiatric pathology-was divided in turn into three sub-groups: "adults" (18-64 years), young elders (65-79), and old elders (over 80 years). The participants underwent psychiatric interviews and completed the Mood Disorder Questionnaire (MDQ), Patient Health Questionnaire (PHQ-9), SF-12, and Brief Social Rhythm Scale (BSRS). Data were compared with national and regional normative data. Results: Older adults in the blue zone demonstrated higher MDQ positivity (22.58%) compared to the national averages (0.87%), without corresponding increases in dysregulated rhythms, depressive symptoms, or reduced quality of life. Younger old persons (65-79 years) showed increased rhythm dysregulation (BSRS score: 20.64 ± 7.02) compared to adults (17.40 ± 6.09, p = 0.040), but this trend was not observed in the oldest group (80+ years). No significant differences were found in the CH3SH and (CH3)2S levels between groups. Conclusions: The hyperactivity observed in older adults from Sardinia's blue zone appears adaptive and not linked to social rhythm dysregulation, depressive symptoms, or a diminished quality of life, suggesting resilience factors which may contribute to longevity. These findings support the potential classification of such hyperactivity as beneficial rather than pathological, warranting further research into biomarkers and psychoeducational interventions to prevent the onset of bipolar disorders in predisposed individuals.

Depression during the COVID pandemic in La Manouba Governorate, Tunisia: A community survey

BACKGROUND

It is difficult to quantify the impact of the COVID-19 pandemic on mental health as many community surveys have limited quality, rely on screening tests to measure mental health conditions and distress, and often use convenience samples. Moreover, robust surveys come mainly from high-income countries.

AIM

To measure the prevalence of depressive disorders with onset during the pandemic in a community of a Lower-Middle-income country (LMIC)-Tunisia.

METHODS

Clinical semi-structured face-to-face interviews were carried out during the pandemic (September-December 2021) by medical doctors among a representative sample of the general population in the governorate of La Manouba, Tunisia. Psychiatric diagnoses were established according to DSM-IV.

RESULTS

The prevalence of Major Depressive Disorder (MDD) started or recurred after the pandemic was 5.66%. The factors associated with MDD were loss of job and considerably diminished income due to the pandemic (OR = 2.1, 95% CI [1.5, 2.9]) and the perception of having the family's financial situation below the Tunisian average (OR = 2.3, 95% CI [1.7, 3.2]). Female sex, marital status as separated/divorced, and having a COVID-19 infection were associated with MDD only in the overall sample and urban areas, but not in rural areas. Age and having loved ones who passed away due to COVID-19 were not associated with MDD.

CONCLUSION

In Tunisia, the pandemic seems to have increased the risk of depression in people experiencing a precarious financial situation, also due to the pre-existing economic crisis. Specific local level factors, such as not establishing a rigid lockdown for an extended period, may have protected young people and allowed for better mourning in families suffering the loss of a loved one.

Prevalence and Risk by Age and Sex of Sleep Dysregulation and Depressive Episodes in Bipolar and Depressive Disorders in a Community Survey in Sardinia, Italy

Background/Objectives: Sleep disturbances often accompany mood disorders and persistent insomnia after mood symptoms have resolved may be a marker of poor outcome. The association between sleep symptoms and mood disorders seems to change with age and sex. This study aims to assess the frequency of depressive episodes and sleep disorders in the general population through an agile screening questionnaire and to evaluate the association of depressive episodes and sleep symptoms by sex and age categories. Methods: 774 women and 728 men from Sardinia aged > 16 years old were enrolled. The Patient Health Questionnaire (PHQ-9) was administered through a computer-assisted telephonic interview. Results: The frequency of depressive episodes was double in women (10.6% vs. 4.4%; p < 0.0001), with the highest values in women > 75 yo (17.4%). The frequency of sleep dysregulation was double in women (18.7% vs. 9.6%; p < 0.0001), with the highest values in women > 75 yo (35.9%) and the lowest in the group of men > 75 yo. The group of young males showed the lowest frequency of depressive episodes (1.4%) and a frequency of sleep dysregulation (9.1%) similar to that of the other groups of age and sex. Sleep dysregulation without depressive episodes presented a higher distribution in the elderly, both in males (20.7%) and in females (18.5%). No significative differences were found across sex and age groups in the distribution of depressive episodes without sleep dysregulation. Conclusions: The use of an agile screener such as PHQ9 in the general population and/or in populations at risk can be a valuable tool in finding those individuals in whom sleep dysregulation may represent an early warning signal, one that may be thoroughly evaluated to identify and treat possible sleep disorders early.

Mood Disorder Questionnaire Positivity in Systemic Lupus Erythematosus and Other Chronic Diseases including Screen Bipolar Disorders or Rhythm and Energy Dysregulation Syndromes (DYMERS)

Introduction

This study explores the issue of paper-and-pencil screening tests for bipolar disorder, often leading to false positives. It discusses hypotheses that connect MDQ positivity with sleep disorders, a decline in health-related quality of life, and the impact of the COVID-19 pandemic on mood disorders. The study proposes that MDQ identifies a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), indicating a stress-related condition. It aims to investigate the association between MDQ positivity and systemic lupus erythematosus (SLE) in comparison to other chronic disorders.

Methods

This case-control study, conducted from April 2019 to February 2020, investigated MDQ positivity in patients with SLE. Ethical approvals were obtained, and statistical analysis was used for data assessment.

Results

This is a case-controlled study where MDQ positivity was significantly higher in systemic lupus erythematosus cases than controls. The analysis compared gender, age, and the presence of depressive episodes between MDQ-positive and MDQ-negative cases, revealing some differences but no significant variations. Interestingly, no association with high prednisone or biologics use was observed. The frequency of MDQ positivity in systemic lupus erythematosus was compared to other chronic pathologies, revealing varying associations with each condition.

Conclusion

This study reveals a high rate of (MDQ) positivity in systemic lupus erythematosus (SLE), associated with the risk of bipolar disorder in SLE. Notable discrepancies in MDQ positivity risk factors between SLE and bipolar disorder are observed. The study emphasizes the ability of MDQ to identify a distinct syndrome characterized by rhythm dysregulation, posing a risk for bipolar disorder and other disorders.

Hyperactivity and Risk for Dysregulation of Mood, Energy, and Social Rhythms Syndrome (DYMERS): Standardization of a Simple One-Item Screener versus the Mood Disorder Questionnaire (MDQ)

Background: This study aims to verify the accuracy of item 10 on the energy level of the Short-Form Health Survey (SF-12) in an item screening according to Mood Disorder Questionnaire (MDQ) results, providing a measure of hyper-energy. Methods: Regression techniques were employed in a dataset comprising 4093 records of respondents to test both linear and nonlinear relationships between predictor and outcome variables (energy level and symptoms considered in the MDQ). We examined the relationship of energy level with cases identified using MDQ with a cut-off of 7. Results: Levels of energy, as rated on item 10 of the SF-12, were related to the MDQ score with sensitivity = 0.72 and specificity = 0.70. In linear regression, the associations were stronger with MDQ items on excessive energy or activity, showing a medium effect size and an explained variance of 10% or higher. A greater association was observed for items on excessive energy and activity, as expected, as well as for items concerning self-confidence, sociability, and talkativeness. Conclusions: This result may have implications for the research on risk factors and the pathogenesis of the dysregulation of mood, energy, and social rhythms syndrome (DYMERS), a syndrome that is hypothesized to occur in stressful conditions like those shown under the COVID-19 pandemic.

Prior Engagement in Physical Activity Correlates with Enhanced Quality of Life Perceptions among Older Adults during COVID-19 Lockdown

BACKGROUND

This longitudinal study aimed to evaluate whether prior engagement in a physical exercise program correlated with enhanced perceptions of quality-of-life components among older adults during the COVID-19 lockdown period.

METHODS

The cohort comprised elderly individuals (aged ≥ 65 years) who had previously partaken in a 12-week randomized controlled trial investigating the effects of a mixed aerobic-anaerobic, moderate-intensity exercise program. Participants' health-related quality of life was assessed using the Short Form Health Survey-12 item (SF-12) at the beginning of the initial trial and, again, one year later during the COVID-19 lockdown. In the exercise group, 44 participants were included, while the control group consisted of 49 participants, with computer-based, double-blind randomization conducted in Cagliari, Italy. The differences in scores for each SF-12 item between the two groups from T0 to T1 were compared using one-way ANOVA with Bonferroni corrections. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 27.

RESULTS

No statistically significant differences were observed on average by age (exercise group vs. control group 72.20 ± 4.78 vs. 72.91 ± 4.77; F = 0.513, p = 0.476). A decrease from T0 to T1 towards a better score on the SF-12 was observed in the exercise group compared to the control group in item 1 (F = 67.463, p < 0.0001); in item 5 (F = 4.319, p = 0.041); item 8 (F = 4.269, p = 0.041); item 9 (F = 10.761, p = 0.001); item 10 (F = 170.433, p < 0.001); and item 11 (F = 4.075, p = 0.046).

CONCLUSIONS

The results suggest that participation in a moderate physical exercise program one year prior may have equipped older adults with better coping mechanisms to navigate the stress and isolation imposed by the COVID-19 lockdown, as reflected by their enhanced scores on quality-of-life components pertaining to mental well-being. Exercise may confer a protective effect against the adverse psychological impacts of stressful events like the pandemic, even among older adults with chronic conditions. This study underscores the potential benefits of exercise interventions for promoting quality of life and preventing mood disorders in the elderly population.

The Impact on Anxiety Symptoms of an Immersive Virtual Reality Remediation Program in Bipolar Disorders: A Randomized Clinical Trial

Background: The objective of this work is to investigate the effectiveness of a cognitive remediation intervention on anxiety symptoms in people with bipolar disorder and the therapeutic effect on people whose anxiety symptoms were above the threshold for a screener and whose comorbidity could be identified as an anxiety disorder. Methods: The experimental intervention included 24 sessions (around 45 min each), two for each week over three months. The entire program was inspired by user-centered rehabilitation principles in a recovery-oriented perspective and an approach to bipolar disorder in an evolutionary and non-discriminating vision. The primary outcomes measure the score of the Zung Self-Rating Anxiety Scale (SAS), hypothesizing a higher decrease in the experimental group than in the control group. The survey has been conducted per the CONSORT guidelines for feasibility studies. Results: We evaluate a decrease in the overall SAS score from T0 to T1 to be higher in the experimental group compared to the control group, indicating an improvement in anxiety symptoms (p < 0.0001). Conclusions: The study suggests that virtual reality could have a role in treating anxiety symptoms and disorders in young adults with bipolar disorders or anxiety symptoms in people with hyperactivity and novelty-seeking behaviorsunder stress and high risk for bipolar disorder.

Improving Quality of Life in Bipolar Disorders with an Immersive Virtual Reality Remediation Training Randomized Controlled Trial (RCT)

Background: Health-related quality of life (H-QoL) is a critical measure in bipolar disorder (BD). Recent trials using virtual reality (VR) have shown potential in improving H-QoL. However, VR's effect on the H-QoL of people with BD needs to be further explored. Methods: This study involved a secondary analysis of a feasibility randomized controlled trial, focusing on "quality of life". Participants (aged 18-75) diagnosed with bipolar disorder were randomized into two groups. The experimental group used the CEREBRUM VR app, while the control group received the usual care. Quality of life was assessed using the Short-Form Health Survey (SF-12). Results: A total of 39 individuals in the experimental group and 25 in the control group represent the final samples. The results showed a greater improvement in the SF-12 total score in the experimental group (8.7%) compared to the control group (F = 66.851 p < 0.0001), specifically in the dimension of physical activity limitation, emotional impact, concentration, pain, calmness, energy levels, discouragement, and social activities. Conclusions: This study demonstrated an improvement in QoL for individuals with BD following a VR intervention. As a feasibility study, this secondary outcome needs to be confirmed by further phase III studies. If confirmed, VR could offer valuable rehabilitation tools and insights into the pathogenesis and treatment of BD.

Improving Social and Personal Rhythm Dysregulation in Young and Old Adults with Bipolar Disorder: Post-Hoc Analysis of a Feasibility Randomized Controlled Trial Using Virtual Reality-Based Intervention

Introduction: Rehabilitative interventions employing technology play a crucial role in bipolar disorder (BD) treatment. The study aims to appraise the virtual reality (VR)-based cognitive remediation (CR) and the interpersonal rhythm approaches to treatment outcomes of BD across different age groups. Methods: Post-hoc analysis of a 12-week randomizedcontrolled cross-over feasibility trial involving people with mood disorders (BD, DSM-IV) aged 18-75 years old: thirty-nine exposed to the experimental VR-based CR vs 25 waiting list controls. People with BD relapse, epilepsy or severe eye diseases (due to the potential VR risks exposure) were excluded. Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN) was used to measure the outcome. Results: Cases and controls did not statistically significantly differ in age and sex distributions. Personal rhythm scores improved over the study follow-up in the experimental vs the control group (APC = 8.7%; F = 111.9; p < 0.0001), both in young (18-45 years) (APC = 5.5%; F = 70.46; p < 0.0001) and, to a lesser extent, older (>46 years) adults (APC = 10.5%; F = 12.110; p = 0.002). Conclusions: This study observed improved synchronization of personal and social rhythms in individuals with BD after a virtual reality cognitive remediation intervention, particularly in social activity, daily activities, and chronotype, with greater benefits in the younger population.

An e-Health Psychoeducation Program for Managing the Mental Health of People with Bipolar Disorder during the COVID-19 Pandemic: A Randomized Controlled Study

Background: Social rhythm dysregulation has been identified as a determining factor in bipolar disorder (BD) relapses. It directly impacts individuals' quality of life (QoL). This study aims to present preliminary data on the efficacy of an e-health psychoeducational intervention for BD for improving clinical outcomes. Methods: This study used an open-label, crossover, randomized controlled trial design. The inclusion criteria consisted of a BD diagnosis, affiliation with the Consultation Psychiatry and Psychosomatic Center at the University Hospital in Cagliari, Italy, age over 18, and the obtaining of informed consent. Anxiety and depressive symptoms, QoL, and social and biological rhythms were measured using standardized instruments validated in Italian. Results: A total of 36 individuals were included in the experimental group (EG) and 18 in the control group (CG). The final sample consisted of 25 in the EG and 14 in the CG. A statistically significant improvement in QoL was found in the EG post-treatment (p = 0.011). Significant correlations were found between QoL and the dysregulation of biorhythms in the EG at T0 (p = 0.0048) and T1 (p = 0.0014). Conclusions: This study shows that, during extreme distress, an e-health group psychoeducation intervention for people with BD could significantly improve the perception of QoL. The results must be confirmed by studies conducted with larger-sized samples.

Stress, Dysregulation of Rhythms, and Bipolar Disorder: A Challenging Field of Research

Clarifying the mechanisms by which circadian rhythms regulate biology is a central issue in directing life choices in the immediate future and presents an interesting challenge for current scientific research [...].

Non-binary gender, vulnerable populations and mental health during the COVID-19 pandemic: Data from the COVID-19 MEntal health inTernational for the general population (COMET-G) study

BACKGROUND

The COVID-19 pandemic has brought significant mental health challenges, particularly for vulnerable populations, including non-binary gender individuals. The COMET international study aimed to investigate specific risk factors for clinical depression or distress during the pandemic, also in these special populations.

METHODS

Chi-square tests were used for initial screening to select only those variables which would show an initial significance. Risk Ratios (RR) were calculated, and a Multiple Backward Stepwise Linear Regression Analysis (MBSLRA) was followed with those variables given significant results at screening and with the presence of distress or depression or the lack of both of them.

RESULTS

The most important risk factors for depression were female (RR = 1.59-5.49) and non-binary gender (RR = 1.56-7.41), unemployment (RR = 1.41-6.57), not working during lockdowns (RR = 1.43-5.79), bad general health (RR = 2.74-9.98), chronic somatic disorder (RR = 1.22-5.57), history of mental disorders (depression RR = 2.31-9.47; suicide attempt RR = 2.33-9.75; psychosis RR = 2.14-10.08; Bipolar disorder RR = 2.75-12.86), smoking status (RR = 1.15-5.31) and substance use (RR = 1.77-8.01). The risk factors for distress or depression that survived MBSLRA were younger age, being widowed, living alone, bad general health, being a carer, chronic somatic disorder, not working during lockdowns, being single, self-reported history of depression, bipolar disorder, self-harm, suicide attempts and of other mental disorders, smoking, alcohol, and substance use.

CONCLUSIONS

Targeted preventive interventions are crucial to safeguard the mental health of vulnerable groups, emphasizing the importance of diverse samples in future research.

LIMITATIONS

Online data collection may have resulted in the underrepresentation of certain population groups.

Can we predict a "tsunami"? Symptomatic and syndromal density, mood instability and treatment intensity in people with bipolar disorders under a strict and long lockdown

BACKGROUND

Converging evidence supports the involvement of circadian rhythm disturbances in the course and morbidity of bipolar disorders (BD). During 2020, lockdown measures were introduced worldwide to contain the health crisis caused by the COVID-19 pandemic. As a result, chronobiological rhythms were critically disrupted and illness outcomes were expected to worsen. The current study aimed to explore changes in morbidity among BD patients living under lockdown.

METHODS

Ninety BD outpatients under naturalistic treatment conditions were followed from March to September 2020 using a mood chart technique. Different treatment and illness variables, including mood instability, were assessed and compared with the outcomes obtained during the same 28-week period in 2019.

RESULTS

For most clinical variables, no significant differences were observed between time periods. A slight decrease was found in symptom intensity (from 15.19 ± 20.62 to 10.34 ± 15.79, FDR-adjusted p = 0.04) and in the number of depressive episodes (from 0.39 ± 0.74 to 0.22 ± 0.63, FDR-adjusted p = 0.03), whereas the intensity of pharmacological treatment remained unchanged. Previous illness course predicted mood outcomes during the confinement.

LIMITATIONS

Follow-up periods were relatively short. Further, actigraphy or other methods capable of ensuring significant changes in physical activity were not used.

CONCLUSIONS

In line with other studies, our findings show no worsening in the clinical morbidity of BD patients during lockdown. This conspicuous contrast between our initial predictions and the observed findings highlights the fact that we are still far from being able to provide accurate predictive models for BD.

Dysregulation of mood, energy, and social rhythms syndrome (DYMERS): A working hypothesis

A syndrome centered on the dysregulation of behavioral rhythms (DBR) is discussed. Recent pandemic brought to observe: (1) Having a DBR affecting sleep patterns, eating habits, and social interactions, before the lockdown period, was a determinant for depressive episodes during the lockdown; (2) In tighter lockdowns, DBR triggered depressive episodes in bipolar patients; (3) DBR in healthcare workers under pressure was a determinant of burnout; (4) DBR influenced the course of chronic diseases by altering immune responses. In addition, it was found that scoring positive on the Mood Disorder Questionnaire (MDQ) was closely associated with the dysregulation of sleep rhythms. MDQ is a screening tool for bipolar disorder (BD), criticized for detecting too many false positives. Studies showed that positivity to the MDQ implied a severe impairment of quality of life even in people without psychiatric diagnoses. According to this evidence, three different hyperactivation levels could be proposed (from normality to pathology): firstly, an adaptive increase in energy (e.g. athletes performing well); secondly, a DBR determined from the continuous stimulation of stress hormones, with possible positive scores on the MDQ without a diagnosis of bipolar disorder, like in burnout syndromes and, thirdly, hyperactivity during manic episodes. The Dysregulation of Mood, Energy, and Social Rhythms Syndrome (DYMERS), the second level of the scale, is proposed as a working hypothesis. DYMERS is also seen as a vulnerable condition that may evolve in other disorders (including BD) according to the individual susceptibility (including genetic predisposition) and the specific nature/level of the stressor.

The Stability of Social and Behavioral Rhythms and Unexpected Low Rate of Relevant Depressive Symptoms in Old Adults during the COVID-19 Pandemic

Background: The disruption of social rhythms was found to be associated with depressive disorders during the COVID-19 pandemic; lower rates of these disorders were surprisingly found in old adults. The present study aims to verify the stability of social rhythms during lockdown in a sample of elderly people. Methods: Controlled cohort study (secondary analyses) of a previous randomized-controlled trial with the first evaluation in April 2019 (T0) and then 48 weeks later (T1) during the lockdown. The regulation of social and behavioral rhythms was measured through the Brief Social Rhythms Scale (BSRS); the Patient Health Questionnaire-9 (PHQ9) was adopted to detect relevant depressive symptoms. Results: 93 elderlies (73.36 ± 4.97 years old, 50.5% females) were evaluated at T0 and T1. Neither the total score of BSRS nor any of the 10 items showed a statistically significant difference comparing the two survey periods. The frequency of relevant depressive symptoms was 5.3% at T0 and 6.4% at T1 (OR = 0.8, CI95% 0.2-24). Conclusions: Among elderlies who did not show an increased risk of depression during the lockdown, social and behavioral rhythms remained exceptionally stable during the same period. Considering previous evidence about rhythms dysregulation preceding depression, their stability may be considered a factor of resilience.

Management of psychiatric treatments of patients diagnosed with bipolar disorder in the COVID-19 pandemic: A one-year evaluation in the pandemic

OBJECTIVE

The course of bipolar disorder (BD) is sensitive to factors that may disrupt biological and social rhythms. It is important for patients diagnosed with BD to continue their follow-up and treatment during the pandemic due to personal and social effects. This study aimed to evaluate the disease course and treatment compliance of individuals diagnosed with BD during the pandemic.

METHODS

A total of 267 patients with BD were included in the study. The scales were applied by phone calls. A sociodemographic data form was filled out during the phone interviews. Diagnostic criteria for hypomanic, manic, and depressive episodes in DSM-5 were questioned and recorded through the created form.

RESULTS

During the first of the pandemic, a total of 72 (27.0%) patients had a mood episode, of which 56 (21.0%) were manic/hypomanic episodes and 16 (6.0%) depressive episodes. Also, 54.7% of the patients were able to obtain their medications thanks to the extended medication reports. Being unable to use their medications regularly, having a seasonal pattern of disease, and using an increased number of psychotropics were significant predictors of a new episode. While 74.5% of the patients wanted to talk to their psychiatrists online, only 1.1% could reach the psychiatrist online.

DISCUSSION

The effects of the COVID-19 pandemic are particularly evident in patients with a seasonal pattern. Telepsychiatry practices should be actively included in clinical practice, and government policies developed for treatment compliance seem important.

Does the Response to a Stressful Condition in Older Adults with Life Rhythm Dysregulations Provide Evidence of the Existence of the "Dysregulation of Mood, Energy, and Social Rhythms Syndrome"?

OBJECTIVE

The COVID-19 lockdown periods have given rise to the "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS). This syndrome is characterized by a poor regulation of biological, social, and behavioral rhythms, including sleep, nutrition, and social contacts. The purpose of this cohort study was to examine whether older adults with pre-existing DYMERS had a more negative perception of their health-related quality of life (H-QoL) during the COVID-19 pandemic lockdown, regardless of the presence of concurrent mood disorders.

METHOD

The entire study population (N = 93; age > 65 year) was categorized based on whether they exhibited dysregulated rhythms at the outset of the study. A comparison was made between DYMERS-positive individuals and DYMERS-negative individuals, and we assessed their H-QoL at the conclusion of the study. We also compared the H-QoL of individuals in the cohort who did not have a positive depression score to understand the impact of the rhythm dysregulation alone.

RESULTS

The frequency of individuals with a critical health-related quality of life score (SF12 < 25) was higher in the cohort with pre-existing DYMERS during lockdown (33.33% vs. 6.17%). This difference remained significant even when only individuals without depressive symptomatology were considered (27.27% vs. 2.60%).

CONCLUSION

The results of this study indicate that DYMERS can exert a substantial influence on health-related quality of life (H-QoL), even when mood disturbances are not present. Additional research is required to investigate the relationship between DYMERS and other psychiatric conditions as well as its nature as a standalone disorder.

Does Screening for Bipolar Disorders Identify a "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS)? A Heuristic Working Hypothesis

The aim of this paper is to verify if people with a positive score on the Mood Disorder Questionnaire (MDQ) without comorbidity of mood disorders showed a worse level of Health-related Quality of life (HRQol) compared to a control-matched sample of MDQ negatives, identifying a specific syndrome. This is a case-control study based on a database from a community survey. Cases: MDQ-positive without mood disorders; Controls: MDQ negatives matched by sex, age, and psychiatric diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria. Tools: MDQ, the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS) semi-structured interview for psychiatric diagnosis, and the Health Survey Short Form (SF-12) for measuring HRQol. People scoring positive on the MDQ without a diagnosis of mood disorders showed significantly lower scores on the SF-12 compared to people of the same age and of the same sex with an equal diagnosis of psychiatric disorders not related to mood disorders (35.21 ± 6.30 vs. 41.48 ± 3.39, p < 0.0001). In the debate whether a positive score on the MDQ selects an area of "malaise" due to the presence of disorders differing from Bipolar Disorders, or if a positive score on the MDQ may be considered a "subthreshold" form of bipolar disorder in people who may later develop bipolar disorder, a third hypothesis can be advanced, i.e., that a positive score on the MDQ identifies a specific "Dysregulation of Mood, Energy, and Social Rhythms Syndrome" (DYMERS), characterized by a considerable amount of suffering and not attributable to other disorders, and which might represent a trigger for the previously mentioned disorders with which a positive score on the MDQ is associated, probably including, in severe conditions, bipolar disorder.

Mental health in Europe during the COVID-19 pandemic: a systematic review

The COVID-19 pandemic caused immediate and far-reaching disruption to society, the economy, and health-care services. We synthesised evidence on the effect of the pandemic on mental health and mental health care in high-income European countries. We included 177 longitudinal and repeated cross-sectional studies comparing prevalence or incidence of mental health problems, mental health symptom severity in people with pre-existing mental health conditions, or mental health service use before versus during the pandemic, or between different timepoints of the pandemic. We found that epidemiological studies reported higher prevalence of some mental health problems during the pandemic compared with before it, but that in most cases this increase reduced over time. Conversely, studies of health records showed reduced incidence of new diagnoses at the start of the pandemic, which further declined during 2020. Mental health service use also declined at the onset of the pandemic but increased later in 2020 and through 2021, although rates of use did not return to pre-pandemic levels for some services. We found mixed patterns of effects of the pandemic on mental health and social outcome for adults already living with mental health conditions.

Is a Genetic Variant associated with Bipolar Disorder Frequent in People without Bipolar Disorder but with Characteristics of Hyperactivity and Novelty Seeking?

Objective

The objective is to verify whether a genetic condition associated with bipolar disorder (BD) is frequent in old adults adapted to their environment, without BD, but with aptitudes for hyperactivity and novelty seeking (H/NS).

Methods

In this cross-sectional study, the study sample included healthy elderly people (40 participants, aged 60 or older) living in an urban area and recruited from a previous study on physical exercise and active aging, who were compared with 21 old adults with BD from the same area. The genetic methodology consisted of blood sampling, DNA extraction, real-time PCR jointly with FRET probes, and the SANGER sequencing method. The genetic variant RS1006737 of CACNA1C, found to be associated with bipolar disorder diagnosis, was investigated.

Results

The frequency of the RS1006737 genetic variant in the study group (H/NS) is not higher than in the BD group and is statistically significantly higher than in all the control groups found in the literature. However, the familiarity for BD is higher in old adults with BD than in the H/NS sample without BD. The risk of BD in the family (also considering those without BD but with family members with BD) is not associated with the presence of the genetic variant examined.

Conclusion

The study suggests that the gene examined is associated with characteristics of hyperactivity rather than just BD. Nevertheless, choosing to participate in an exercise program is an excessively general way to identify H/NS. The next step would be to identify the old adults with well-defined H/NS features with an adequate tool.

Development and Validation of the Questionnaire for Adaptive Hyperactivity and Goal Achievement (AHGA)

Objective

This paper illustrates the preliminary psychometric properties of the Questionnaire for Adaptive Hyperactivity and Goal Achievement (AHGA), aimed at measuring adaptive characteristics of hyperactivity and goal pursuit in older adults.

Methods

The 12-item scale was administered to a sample of 120 subjects (older adults) between February 2022 and June 2022. The reliability of AHGA was measured using Cronbach's alpha, and factor structure was established using parallel analysis (PA) and principal component analysis (PCA). Convergent validity was tested against the Biological Rhythms Interview of Assessment in Neuropsychiatry (BRIAN).

Results

All included subjects have an average age of 74.1±5.1 years. AHGA reliability was good (Cronbach's alpha: 0.713 [95%CI: 0.630 to 0.783]). Factor analysis suggested two main components: goal achievement and hyperactivity, which explained 41% of the variance in the data. The results support the convergent validity of the scale: AHGA measures adaptive characteristics of hyperactivity and goal pursuit, in contrast to BRIAN, which measures pathological characteristics.

Conclusion

The reported findings represent an innovative approach to hyperthymic features by embracing a broader spectrum concept that conceptualizes the potential transition between pathological and adaptive aspects as a continuum.

A Recovery-Oriented Program for People with Bipolar Disorder through Virtual Reality-Based Cognitive Remediation: Results of a Feasibility Randomized Clinical Trial

BACKGROUND

Cognitive impairment is a frequent consequence of bipolar disorder (BD) that is difficult to prevent and treat. In addition, the quality of the preliminary evidence on the treatment of BD through Cognitive Remediation (CR) with traditional methods is poor. This study aims to evaluate the feasibility of a CR intervention with fully immersive Virtual Reality (VR) as an additional treatment for BD and offers preliminary data on its efficacy.

METHODS

Feasibility randomized controlled cross-over clinical study, with experimental condition lasting three months, crossed between two groups. Experimental condition: CR fully immersive VR recovery-oriented program plus conventional care; Control condition: conventional care. The control group began the experimental condition after a three months period of conventional care (waiting list). After the randomization of 50 people with BD diagnosis, the final sample consists of 39 participants in the experimental condition and 25 in the control condition because of dropouts.

RESULTS

Acceptability and tolerability of the intervention were good. Compared to the waitlist group, the experimental group reported a significant improvement regarding cognitive functions (memory: p = 0.003; attention: p = 0.002, verbal fluency: p = 0.010, executive function: p = 0.003), depressive symptoms (p = 0.030), emotional awareness (p = 0.007) and biological rhythms (p = 0.029).

CONCLUSIONS

The results are preliminary and cannot be considered exhaustive due to the small sample size. However, the evidence of efficacy, together with the good acceptability of the intervention, is of interest. These results suggest the need to conduct studies with larger samples that can confirm this data.

TRIAL REGISTRATION

ClinicalTrialsgov NCT05070065, registered in September 2021.

Fully Immersive Virtual Reality-Based Cognitive Remediation for Adults with Psychosocial Disabilities: A Systematic Scoping Review of Methods Intervention Gaps and Meta-Analysis of Published Effectiveness Studies

BACKGROUND

Cognitive Remediation (CR) programs are effective for the treatment of mental diseases; in recent years, Virtual Reality (VR) rehabilitation tools are increasingly used. This study aimed to systematically review and meta-analyze the published randomized controlled trials that used fully immersive VR tools for CR programs in psychiatric rehabilitation. We also wanted to map currently published CR/VR interventions, their methods components, and their evidence base, including the framework of the development intervention of CR in fully immersive VR.

METHODS

Level 1 of evidence. This study followed the PRISMA extension for Scoping Reviews and Systematic Review. Three electronic databases (Pubmed, Cochrane Library, Embase) were systematically searched, and studies were included if they met the eligibility criteria: only randomized clinical trials, only studies with fully immersive VR, and only CR for the adult population with mental disorders.

RESULTS

We found 4905 (database) plus 7 (manual/citation searching articles) eligible studies. According to inclusion criteria, 11 studies were finally reviewed. Of these, nine included patients with mild cognitive impairment, one with schizophrenia, and one with mild dementia. Most studies used an ecological scenario, with improvement across all cognitive domains. Although eight studies showed significant efficacy of CR/VR, the interventions' development was poorly described, and few details were given on the interventions' components.

CONCLUSIONS

Although CR/VR seems to be effective in clinical and feasibility outcomes, the interventions and their components are not clearly described. This limits the understanding of the effectiveness and undermines their real-world implementation and the establishment of a gold standard for fully immersive VR/CR.

Mental Health Impact of Early Stages of the COVID-19 Pandemic on Individuals with Pre-Existing Mental Disorders: A Systematic Review of Longitudinal Research

In view of disease-related threats, containment measures, and disrupted healthcare, individuals with pre-existing mental illness might be vulnerable to adverse effects of the COVID-19 pandemic. Previous reviews indicated increased mental distress, with limited information on peri-pandemic changes. In this systematic review, we aimed to identify longitudinal research investigating pre- to peri-pandemic and/or peri-pandemic changes of mental health in patients, focusing on the early phase and considering specific diagnoses. PsycINFO, Web of Science, the WHO Global literature on coronavirus disease database, and the Cochrane COVID-19 Study Register weresearched through 31 May 2021. Studies were synthesized using vote counting based on effect direction. We included 40 studies mostly from Western, high-income countries. Findings were heterogeneous, with improving and deteriorating mental health observed compared to pre-pandemic data, partly depending on underlying diagnoses. For peri-pandemic changes, evidence was limited, with some suggestion of recovery of mental distress. Study quality was heterogeneous; only few studies investigated potential moderators (e.g., chronicity of mental illness). Mental health effects on people with pre-existing conditions are heterogeneous within and across diagnoses for pre- to peri-pandemic and peri-pandemic comparisons. To improve mental health services amid future global crises, forthcoming research should understand medium- and long-term effects, controlling for containment measures.

Is Bipolar Disorder the Consequence of a Genetic Weakness or Not Having Correctly Used a Potential Adaptive Condition?

It is hypothesized that factors associated with bipolar disorder could, uer defined conditions, produce adaptive behaviors. The aim is to verify whether a genetic feature associated with bipolar disorder can be found in people without bipolar disorder but with hyperactivity/exploration traits. Healthy old adults (N = 40) recruited for a previous study on exercise were subdivided using a previously validated tool into those with and without hyperactivity/exploration traits and compared with a group of old patients with bipolar disorder (N = 21). The genetic variant RS1006737 of CACNA1C was analyzed using blood samples, DNA extraction, real-time PCR, FRET probes, and SANGER method sequencing. People with hyperactivity/exploration traits and without bipolar disorder were like people with bipolar disorder regarding the frequency of the genetic variant (OR = 0.79, CI95%: 0.21-2.95), but were different from people without either hyperactivity/exploration traits and bipolar disorder (OR = 4.75, CI95%: 1.19-18.91). The combined group of people with hyperactivity/exploration traits without bipolar disorder plus people with bipolar disorder had a higher frequency of the variant than people without either hyperactivity/exploration traits or bipolar disorder (OR = 4.25, CI95%: 1.24-14.4). To consider the genetic profile of bipolar disorder not an aberrant condition opens the way to a new approach in which the adaptive potential would be a central point in psychosocial treatment in addition to drug therapy. Future research can confirm the results of our study.

Prevalence of Mood Disorders and Associated Factors at the Time of the COVID-19 Pandemic: Potocol for a Community Survey in La Manouba Governorate, Tunisia

Aims

The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic.

Background

Mood disorders are one of the leading causes of all non-fatal burdens of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle-income countries (LMICs) and in vulnerable populations.

Objective

1/ Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders; 2/Study socio-demographic and clinical correlates of mood disorders 3/ Assess the association between mood disorders and quality of life 4/ Study the impact of the COVID-pandemic on the prevalence of mood disorders 5/ Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic.

Methods

This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered.

Results

Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about a headache. In addition, socio-demographic and clinical data will be collected.

Conclusion

This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19-related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

Social Rhythm Disruption is Associated with Greater Depressive Symptoms in People with Mood Disorders: Findings from a Multinational Online Survey During COVID-19

OBJECTIVES

Societal restrictions imposed to prevent transmission of COVID-19 may challenge circadian-driven lifestyle behaviours, particularly amongst those vulnerable to mood disorders. The overarching aim of the present study was to investigate the hypothesis that, in the routine-disrupted environment of the COVID-19, amongst a sample of people living with mood disorders, greater social rhythm disruption would be associated with more severe mood symptoms.

METHODS

We conducted a two-wave, multinational survey of 997 participants (MAge=39.75±13.39,Female=81.6%) who self-reported a mood disorder diagnosis (i.e., major depressive disorder or bipolar disorder). Respondents completed questionnaires assessing demographics, social rhythmicity (The Brief Social Rhythm Scale), depression symptoms (Patient Health Questionnaire-9), sleep quality and diurnal preference (The Sleep, Circadian Rhythms and Mood questionnaire) and stressful life events during the COVID-19 pandemic (The Social Readjustment Rating Scale).

RESULTS

The majority of participants indicated COVID-19-related social disruption had affected the regularity of their daily routines to at least some extent (n = 788, 79.1%). As hypothesised, lower social rhythmicity was associated with greater depressive symptoms when tested cross-sectionally (standardised β = -.25, t = -7.94, P = 0.000) and when tested using a 2-level hierarchical linear model across two time points (b = -0.14, t = -3.46, df = 264, P ≤ 0.001).

CONCLUSIONS

These results are consistent with the social zeitgeber hypothesis proposing that mood disorders are sensitive to life events that disrupt social rhythms.

Pandemic experiences and psychopathological aspects in individuals with mood disorders and other mental disorders

Individuals with different personality traits, temperaments, and psychological symptoms have different attitudes toward the pandemic experiences and restrictive measures. The aim of the present study was to evaluate the associations between the psychological factors and the attitudes toward COVID-19, experienced during the third pandemic wave in Italy, in a sample of individuals with psychiatric disorders. Between March and September 2021, 53 patients with mood disorders and other mental disorders completed a survey composed of self-report questionnaires that assessed sleep quality, depressive and hypomanic symptoms, and temperament and personality traits. Positive and negative attitudes toward the pandemic experience were assessed using an ad hoc questionnaire. The results showed that individuals with more severe depressive symptoms were less prone to adhere to government guidelines, and were more convinced that the pandemic was not a real problem. Reduced sleep quality was associated with increased skepticism toward official explanations concerning the causes of COVID-19. Lastly, negative affect and cyclothymic temperament predicted the disposition toward COVID-19 vaccines. In conclusion, these findings highlighted that some psychological aspects and psychiatric symptoms could influence the beliefs about COVID-19 and compliance with government recommendations. Further research is needed to provide indications on how to improve the current healthcare policies.

Cognitive Remediation Virtual Reality Tool a Recovery-Oriented Project for People with Bipolar Disorder: Protocol of a Feasibility Randomized Clinical Trial

Introduction

Cognitive deficits are considered a fundamental component of bipolar disorder due to the fact that they negatively impact personal/social functioning. Cognitive remediation interventions are effective in the treatment of various psychosocial disorders, including bipolar disorder. The use of Virtual reality as a rehabilitation tool has produced scientific evidence in recent years, especially in cardiovascular, neurological, and musculoskeletal rehabilitation. This study aims at evaluating the feasibility of a Cognitive Remediation Virtual Reality Program (CEREBRUM) for people with bipolar disorder in psychiatric rehabilitation.

Material and Methods

Feasibility randomized controlled cross-over clinical study; we randomized 50 people from the Consultation and Psychosomatic Psychiatry Center of the University Hospital of Cagliari (San Giovanni di Dio Civil Hospital) with a diagnosis of bipolar disorder. We propose a cognitive remediation program in virtual reality (CEREBRUM), 3 months with 2 weekly sessions, for the experimental group and a usual care program for the control group (psychiatric visit and/or psychotherapy).

Results

The results of the trial will be published in international peer-reviewed journals and will be disseminated at international meetings and congress.

Discussion

This RCT aims, with regards to its feasibility and design, to provide information about a confirmatory trial that evaluates the effectiveness of a Virtual Reality Cognitive Remediation program in psychiatric rehabilitation for the treatment of cognitive dysfunction in people with bipolar disorder.

Conclusion

The results that we analyzed at the end of the RCT will have an impact on psychiatric rehabilitation research with a focus on improving the application of technologies for mental health.Trial registration: ClinicalTrialsgov NCT05070065, registered on September 2021.

The Current Quality of Web-Based Information on the Treatment of Bipolar Disorder: A Systematic Search

Background: An important aspect of managing chronic disorders like bipolar disorder is to have access to relevant health information. This study investigates and compares the quality of information on the treatments of bipolar disorder that is available on English websites, as an international language, and on Italian websites, as a popular local language. Methods: A systematic review search was obtained from four search engines. We excluded unrelated materials, scientific papers, and duplicates. We analyzed popularity with PageRank; technological quality with Nibbler; readability with the Flesh Reading Ease test and Gulpease index; quality of information with the DISCERN scale, the JAMA benchmark criteria, and on the extent of adherence to the HONCode. Results: 35 English and 31 Italian websites were included. The English websites were found to have a higher level of quality information and technological quality than the Italian ones. Overall, the websites were found to be difficult to read, requiring a high level of education. Conclusions: These results can be important to inform guidelines for the improvement of health information and help users to reach a higher level of evidence on the websites. Users should find the benefits of treatment, support for shared decision-making, the sources used, the medical editor’s supervision, and the risk of postponing treatment.

The Relationship between Mental Disorders and the COVID-19 Pandemic—Course, Risk Factors, and Potential Consequences

In this review the authors discuss that COVID-19 has already had a direct impact on the physical health of many people and that it appears to have put at risk the mental health of large populations. In this review, we also discuss the relationship between mental disorders and the SARS-CoV-2 infection. We convey the disorders’ risk factors and the more serious mental disorder consequences of COVID-19. People with mental health disorders could be more susceptible to the emotional responses brought on by the COVID-19 epidemic. The COVID-19 pandemic may adversely influence the mental health of patients with already diagnosed mental disorders. For the aim of dealing better with the psychological problems of people afflicted by the COVID-19 pandemic, new psychological procedures are required.

Differences in lethality and diffusion of Covid-19 in countries using different kinds of vaccines

To verify if lethality and diffusivity of Covid-19 correlated with percentage of people vaccinated in different countries and whether results on these indicators were comparable under different types of vaccines. A linear regression analysis was conducted between vaccines/inhabitant, new cases/inhabitants and ratio deaths/cases. A comparison between the three indicators was carried out in countries subdivided by kind of vaccine. The proportion of vaccinations/inhabitants correlates negatively with proportion of deaths × 100 cases (R = -3.90, p < 0.0001), but didn't on incidence of new cases. Countries with prevalence of mRNA vaccines were similar to others on incidence of new cases; but a lower lethality of Sars-Cov2 was found than in countries with prevalence of viral vehicle vaccines (F = 6.064, p = 0.0174) but didn't against countries with prevalence of inactivated vaccines. The higher is the proportion of vaccine/inhabitant in a given country, the less is the fraction of infected people who die.

Greater Emotional Distress Due to Social Distancing and Greater Symptom Severity during the COVID-19 Pandemic in Individuals with Bipolar Disorder: A Multicenter Study in Austria, Germany, and Denmark

Throughout the COVID-19 pandemic, mental health of individuals with bipolar disorders (BD) is potentially more vulnerable, especially regarding COVID-19-related regulations and associated symptomatic changes. A multicentric online study was conducted in Austria, Germany, and Denmark during the COVID-19 pandemic. Overall, data from 494 participants were collected (203 individuals with BD, 291 healthy controls (HC)). Participants filled out questionnaires surveying emotional distress due to social distancing, fear of COVID-19, and the Brief Symptom Inventory-18 to assess symptom severity at four points of measurement between 2020 and 2021. General linear mixed models were calculated to determine the difference between the groups in these pandemic specific factors. Individuals with BD reported higher distress due to social distancing than HC, independently of measurement times. Fear of COVID-19 did not differ between groups; however, it was elevated in times of higher infection and mortality due to COVID-19. Individuals with BD reported higher psychiatric symptom severity than HC; however, symptom severity decreased throughout the measured time in the pandemic. Overall, individuals with BD experienced more distress due to the COVID-19 situation than HC. A supportive mental health system is thus recommended to ensure enhanced care, especially in times of strict COVID-19-related regulations.

Psychological and behavioral response on the COVID-19 pandemic in individuals with bipolar disorder: A multicenter study

The COVID-19 pandemic affects both mentally healthy and ill individuals. Individuals with bipolar disorder (BD) constitute an especially vulnerable group. A multicentric online study was conducted in Austria, Denmark, and Germany after the first lockdown phase in 2020. In total, 117 healthy controls (HC) were matched according to age and sex to 117 individuals with BD. The survey included the Brief Symptom Inventory-18, Beck Depression Inventory-2, Pittsburgh Sleep Quality Index, and a self-constructed questionnaire assessing COVID-19 fears, emotional distress due to social distancing, lifestyle, and compliance to governmental measures. In individuals with BD, increased symptoms of depression, somatization, anxiety, distress due to social distancing, and poorer sleep quality were related to emotional distress due to social distancing. The correlation between emotional distress due to social distancing and anxiety showed 26% of shared variance in BD and 11% in HC. Negative lifestyle changes and lower compliance with COVID-19 regulatory measures were more likely to be observed in individuals with BD than in HC. These findings underscore the need for ongoing mental health support during the pandemic. Individuals with BD should be continuously supported during periods of social distancing to maintain a stable lifestyle and employ strategies to cope with COVID-19 fears.

Respect for service users’ human rights, job satisfaction, and wellbeing are higher in mental health workers than in other health workers: A study in Italy at time of the Covid pandemic

Background:

This study aimed to evaluate the respect for users’ rights, job satisfaction, and well-being between mental health workers (MHWs) compared to non-mental health care workers (nMHWs) from the same Italian region.

Methods:

The sample was recruited from community mental health and non-mental health outpatient centers in Sardinia. Participants fulfilled the WellBeing at work and respect for human-rights questionnaire (WWRR). The sample included 240 MHWs and 154 nMHWs.

Results:

MHWs were more satisfied with their work and workplace compared to nMHWs. MHWs had stronger beliefs that users were satisfied with the care received, and both workers and users’ human rights were respected in their workplace. MHWs reported to need more rehabilitation therapists and psychologists in their services, while nMHWs needed more nurses and professionals for users’ personal care. Italian MHWs are more satisfied with their work and workplace, and more convinced that users are satisfied with the care received and that users’ and staff human rights are respected in their workplaces, compared to nMHWs.

Conclusions:

The historic link between the community mental health network and other support networks in Italy and the consequent perception of proximity to the citizens of the care network may be the reason for this optimal situation of Italian MHWs.

Previous functional social and behavioral rhythms affect resilience to COVID-19-related stress among old adults

BACKGROUND

Functioning of Social Behavioral Rhythms (SBRs) may affect resilience toward stressful events across different age groups. However, the impact of SBRs on the coronavirus disease of 2019 (COVID-19) in elder people is yet to ascertain, representing the aim of the present report.

DESIGN AND METHODS

Follow-up of a peer-reviewed randomized controlled trial on exercise on old adults (³65 years), concurrent to the onset of the pandemic-related lockdown. Post-RCT evaluations occurred after further 12 and 36 weeks since the beginning of the lockdown phase. People with Major Depressive Episode (MDE) at week-48 (follow-up endpoint) were deemed as cases, people without such condition were considered controls. MDE was ascertained using the Patient Health Questionnaire-9 (PHQ-9); SBRs functioning at week 12 onward, through the Brief Symptom Rating Scale (BSRS).

RESULTS

Seventy-nine individuals (53.2%, females) entered the RCT-follow-up phase. The frequency of MDE did not significantly change before versus during lockdown (OR 2.60, CI95%=0.87-9.13). People with BSRS>1 standard deviation of the whole sample score at week-12 had an inflated risk of DE during lockdown (OR=5.6, 95%CI: 1.5-21.4) compared to those with lower BSRS scores. Such odd hold after excluding individuals with MDD at week-12. The post-hoc analysis could be potentially affected by selection bias.

CONCLUSIONS

Overall, older adults were resilient during the first phase of the pandemic when functioning of pre-lockdown was still preserved, in contrast to the subsequent evaluations when the impairment of daily rhythms was associated with impaired reliance.

Exercise in Older Adults to Prevent Depressive Symptoms at the Time of Covid-19: Results of a Randomized Controlled Trial with Follow-Up

Background

This study aimed to verify, through a randomized controlled trial, whether a medium-intensity mixing/aerobic/anaerobic exercise (accessible to older adults even with mild chronic diseases) can effectively counteract depressive episodes. A characteristic of the trial was that the follow-up coincided (unscheduled) with the lockdown due to Covid-19.

Methods

Participants (N=120) were randomized into an intervention group, performing physical exercise, and a control group. Participants, aged 65 years and older, belonged to both genders, living at home, and cleared a medical examination, were evaluated with a screening tool to detect depressive episodes, the PHQ9, at pre-treatment, end of the trial (12-week), and follow-up (48-week).

Results

A decrease in the frequency of depressive episodes after the trial (T1) was found in both groups; however, a statistically significant difference was observed only in the control group (p=0.0039). From T1 to follow-up (conducted during the lockdown), the frequency of depressive episodes increased in the control group, reaching a frequency equal to the time of study entry (p=0.788). In the experimental group, the frequency of depressive episodes did not change at the end of the trial but reached a statistically significant difference compared to the start of the study (p = 0.004) and was higher than the control group (p=0.028).

Conclusion

Moderate-intensity physical exercise can be conducted safely, benefitting older adults even suffering from mild chronic disorders. Physical exercise seems to guarantee a long-term preventive effect towards depressive symptoms, especially in serious stressful situations such as the lockdown due to the Covid-19 pandemic.

Clinical Trial Registration Number NCT03858114

Circadian disturbances, sleep difficulties and the COVID-19 pandemic

The COVID-19 pandemic has imposed extraordinary and unpredictable changes on our lifestyle for an unknown duration. Consequently, core aspects of wellbeing including behavior, emotion, cognition, and social interactions are negatively affected. Sleep and circadian rhythms, with an extensive impact on physiology, behavior, emotion, and cognition are affected too. We provided an updated overview of the impact of the COVID-19 pandemic on circadian rhythms and sleep based on the results of published studies (n = 48) in three sections. First, we focus on circadian misalignment due to the pandemic in the general population (including shift workers, health staff, students) and COVID-19 patients and summarize the most critically contributing factors to circadian misalignment. Next, we address sleep difficulties and poor sleep quality during the pandemic, their contributing factors, rate and prevalence, and their effects on both the general population and COVID-19 patients. Finally, we summarize the currently applied/recommended interventions for aligning circadian rhythms and improving sleep quality in both, the general population, and COVID-19 patients during the pandemic situation. Briefly, circadian misalignment and sleep difficulties are common consequences of the pandemic in the general population (with elderly, students, children, health and night-work shifters as risk groups) and COVID-19 patients. Home confinement and its physiological, circadian, and psychological derivates are central to these difficulties. Symptoms severity, treatment progress, recovery duration, and even diagnosis of COVID-19 patients are considerably affected by circadian and sleep difficulties. Behavioral interventions for normalizing the factors that contribute to circadian and sleep difficulties are helpful.

Why Was the Perception of Human Rights Respect and Care Satisfaction So High in Users of Italian Mental Health Services during the COVID-19 Pandemic?

The aim of this study was to compare users' and mental health workers' (MHW) perception of respect of human rights and job/care satisfaction in mental health services in Italy during the COVID-19 pandemic. A sample of users and MHW of Sardinia, Italy, fulfilled the "Well-Being at work and respect for human rights questionnaire" (WWRR). The study included 240 MHW and 200 users. Users showed a higher level of satisfaction of care than MHW of work, and a higher perception of the satisfaction of users and human rights respected for health workers. Both user and MHW responses were about 85% of the maximum score, except for satisfaction with resources. Responses were higher for users, but users and MHW both showed high levels of satisfaction. In previous surveys, MHW of Sardinia showed higher scores in all items of WWRR, except for satisfaction with resources, compared with workers from other health sectors of the same region, and with MHW from other countries. The low score for satisfaction with resources (in users and staff) is consistent with a progressive impoverishment of resources for mental health care in Italy. The study, although confirming the validity of the Italian model, fully oriented towards community, sets off an alarm bell on the risks resulting from the decrease in resources.

A longitudinal study of post-traumatic stress, depressive and anxiety symptoms trajectories in subjects with Bipolar Disorder during the COVID-19 pandemic

Background

Bipolar disorder (BD) is recognized to be at high risk for developing negative psychopathological sequelae to potentially traumatic events. Nevertheless, scant data are still available about the effects of the COVID-19 emergency on the clinical course of BD. The present study examined prospectively the development and trajectories of post-traumatic stress, depressive, and anxiety symptoms among subjects with BD that were followed in an outpatient psychiatric clinic at the time of pandemic onset.

Methods

A cohort of 89 subjects with BD was enrolled during the first wave of the COVID-19 pandemic, and assessed at baseline (T0), 2-months (T1), and 6-months (T2) follow-up. A K-means cluster analysis was used to identify distinct trajectories of depressive, anxiety, and post-traumatic stress symptoms during the three time points.

Results

We identified three trajectories: the Acute reaction (13.5%); the Increasing severity (23.6%); and the Low symptoms (62.9%) groups, respectively. In the Acute reaction group a significant prevalence of female gender was reported with respect to the Low symptoms one. Subjects in the Increasing severity group reported significantly lower employment rate, and higher rate of relatives at risk for COVID-19 medical complications. Subjects in the Increasing Severity group reported higher rates of previous hospitalization and manic symptoms at baseline than those included in the Low symptoms one.

Conclusions

Our results describe three distinct symptom trajectories during the COVID-19 emergency in a cohort of subjects suffering from BD, suggesting the need of a long-term follow-up for detecting the impact of the COVID-19 pandemic in this vulnerable population.

Decrease in Social Zeitgebers Is Associated With Worsened Delayed Sleep-Wake Phase Disorder: Findings During the Pandemic in Japan

BACKGROUND

Delay in sleep-wake rhythms was observed in the general population during the coronavirus disease 2019 (COVID-19) pandemic. Patients with delayed sleep-wake phase disorder (DSWPD) may have also experienced exacerbation of symptoms, but no studies have investigated this topic. In this study, we aimed to retrospectively examine the changes in symptoms of outpatients with DSWPD both before and during the pandemic and to identify the factors associated with the exacerbation of sleep-wake rhythms.

METHODS

We included outpatients with DSWPD aged 16 years or older who visited the outpatient clinic due to sleep disorders between January and September 2020. Decreased social zeitgebers was defined as a reduction of 50% or more in the frequency of commuting to school or work during the COVID-19 pandemic. The severity of DSWPD was assessed using the clinical global impressions - severity of illness (CGI-S) at two points: before and during the pandemic. We defined the worsened, unchanged, and improved groups as those whose CGI-S scores worsened by at least one point, remained unchanged, and improved by at least one point, respectively. Multivariate logistic regression analysis was performed to determine the factors associated with worsened DSWPD symptoms.

RESULTS

Sixty patients with DSWPD were eligible for this study. Even before the pandemic, patients who were unemployed or did not attend school tended to show more severe DSWPD symptoms. During the pandemic, 27 patients belonged to the worsened group; 28 patients, unchanged group; and 5 patients, improved group. Decreased social zeitgebers (odds ratio [OR] = 6.668, 95% confidence interval [CI]: 1.653-26.891, p < 0.05) and comorbid mood disorders (OR = 8.876, 95% CI: 1.714-45.974, p < 0.05) showed independent significant associations with the worsening of DSWPD symptoms.

CONCLUSIONS

During the pandemic, the symptoms of DSWPD tended to worsen. The obtained findings emphasize the importance of social zeitgebers, suggesting the need for external motivation in DSWPD treatment.

Implications of the COVID-19 pandemic for people with bipolar disorders: A scoping review

INTRODUCTION

The COVID-19 (coronavirus disease 2019)-related pandemic represents a global source of societal and health burden. Yet, the impact of the pandemic on people with severe mental illness, including bipolar disorder (BD), remains unclear, warranting scoping review on the matter.

METHODS

The MEDLINE and EMBASE databases were systematically searched from inception up to April 24, 2021, adopting broad inclusion criteria to assess a variety of clinical and public health themes related to people with a primary diagnosis of BD during the COVID-19 pandemics. The present work complying with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) registered in the Open Science Framework (OSF) repository (https://osf.io/7evpx/).

RESULTS

Fourteen papers informed the present scoping review. Four major themes were identified: (i) impact of COVID-19-related stressors on BD; (ii) impact of COVID-19 on mental health service utilization among people with BD; (iii) impact of BD on the risk of acquiring SARS-CoV-2 infection; (iv) engagement in preventative behaviors among people with BD. Additional themes warranting further research were nonetheless detected.

LIMITATIONS

Further original studies are needed.

CONCLUSION

The present study confirmed the high-vulnerability hypothesis concerning people with BD versus the general population, reinforcing the need for further research related to the COVID-19 pandemic. Additional information is warranted to compare the impact of the pandemic period among BD people against pre-pandemic records, the general population, and other severe mental illnesses, namely people with schizophrenia or major depressive disorder, to inform the public health and the delivery of patient-tailored interventions.

Effects of the COVID-19 pandemic in a preexisting longitudinal study of patients with recently diagnosed bipolar disorder: Indications for increases in manic symptoms

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic interfered in the daily lives of people and is assumed to adversely affect mental health. However, the effects on mood (in)stability of bipolar disorder (BD) patients and the comparison to pre-COVID-19 symptom severity levels are unknown.

METHOD

Between April and September, 2020, symptoms and well-being were assessed in the Bipolar Netherlands Cohort (BINCO) study of recently diagnosed patients with BD I and II. The questionnaire contained questions regarding manic and depressive symptoms (YMRS and ASRM, QIDS), worry (PSWQ), stress (PSS), loneliness, sleep, fear for COVID-19, positive coping, and substance use. As manic, depressive and stress symptoms levels were assessed pre-COVID-19, their trajectories during the lockdown restrictions were estimated using mixed models.

RESULTS

Of the 70 invited BD patients, 36 (51%) responded at least once (mean age of 36.7 years, 54% female, and 31% BD type 1) to the COVID-19 assessments. There was a significant increase (X² = 17.06; p = .004) in (hypo)manic symptoms from baseline during the first COVID-19 wave, with a decrease thereafter. Fear of COVID-19 (X² = 18.01; p = .003) and positive coping (X²  = 12.44; p = .03) were the highest at the start of the pandemic and decreased thereafter. Other scales including depression and stress symptoms did not vary significantly over time.

CONCLUSION

We found a meaningful increase in manic symptomatology from pre-COVID-19 into the initial phases of the pandemic in BD patients. These symptoms decreased along with fear of COVID-19 and positive coping during the following months when lockdown measures were eased.