Negative Symptoms and Cognitive Deficits in Primary Psychoses: an Observational Study in a Psychiatric Rehabilitation Centre.

Negative symptoms (NSs) and cognitive deficits (CDs) negatively affect patients' quality of life with primary psychosis. Our observational study evaluated the percentage of NSs in a group of inpatients of a psychiatric rehabilitation facility and the variation of the interaction with CDs during the COVID-19 pandemic. The results showed a significant correlation between NSs and CDs in the first observation period (PANSS - FSNS p=0.001; BNSS p=0.023; Epitrack p=0.00) and a stabilization of the results between the first and second observation periods (PANSS - FSNS: p=0.094; BNSS p=0.466; Epitrack p=0.026).

G.T. MSRS On-Line Calculator Targeting the Early Diagnosis of Mixed Affective States: the Multicenter Study Project Design on the Approbation and Validity of the Three Language Versions of the Rating Scale.

BACKGROUND: Mixed affective states (MS) are often misdiagnosed by the clinicians and lead to the inappropriate treatment strategies contributing to the severe forms, poor outcome with higher rates of comorbid conditions and worse remission quality in affective and bipolar disorders, as well as to a decreased psychosocial functioning of these patients. The development of reliable tools for the MS assessments or so called the phenomenon of mixity in affective disorders, is still an unmet need of psychiatric research and clinical practice. In this paper, we present PC program "Multilingual IBM-PC on-line calculator for early diagnosis of the mixed affective states" based on the Giuseppe Tavormina Mixed States Rating Scale (G.T. MSRS) (Russian, English, Italian language versions) created by the ICERN group using programming language JavaScript, working for such operation systems (OS) as Windows, Linux, MacOs, Android, iOS, and aims to contribute to the accurate assessment of the presence and severity of the mixed states among affective disorders. SUBJECTS AND METHODS: The G.T. Mixed States Rating Scale on-line calculator consists of 11 items which evaluate various aspects of MS in patients with major depression, bipolar or recurrent depressive disorder. A total score is automatically calculated, considering the type of affective temperament according to the Akiskal's and Tavormina's schemas, thus, the specific sub-groups of MS are differentiated based on the ranges: Medium-light (2-6), Medium (7-12), and High (13-19) Mixity level. The study will enroll 330 participants during two (three months follow-up) visits (110 native speakers in each of the three languages) of both genders aged from 18 till 55 y.o. with the diagnoses of depressive episodes, major depression, bipolar or recurrent depressive disorder according to the DSM-5 criteria. Assessments will be provided by the two investigators (second one will be blinded to the G.T. MSRS results obtained by the first researcher), based on the use of DSM-5 clinical interview, Young Mania Rating Scale, Montgomery-Åsberg Depression Rating Scale, Clinical Global Impression - Severity scale (CGI-S), Clinical Global Impression - Improvement scale (CGI-I), Patient Global Impression of Change (PGIC). RESULTS: The study will assess the agreement between the diagnostic category/clinical impression and the on-line G.T. MSRS calculator use results, its test-retest reliability, and diagnosis stability for further assessment of the on-line G.T. MSRS calculator validity and clinical utility. Secondary variables will evaluate internal reliability and such statistical analyses as Cronbach's alpha, Cohen's Kappa, biserial correction, and agreement between initial and follow-up diagnoses. CONCLUSIONS: Current multicenter validation study of the on-line G.T. MSRS calculator will enhance the understanding of the mixity phenomenon and its clinical implication, aiming to improve the treatment strategies to manage the course of mental disorder, quality of life and psychosocial functioning in patients with affective (bipolar) disorders, accompanied by MS, and a clinical recommendation for the routine administration of the user-friendly on-line G.T. MSRS version in clinical practice.

The Interference of Negative Symptoms of Schizophrenia on Cognitive Domains: a Long-Term Observational Study on the Role of Clozapine.

The negative symptoms of schizophrenia are responsible for patients' worse quality of life. The association with cognitive deficits impairs clinical and psychopathological conditions. Our small 5-year observational study evaluated the efficacy of clozapine in negative and cognitive symptoms in schizophrenia inpatients. The overall results showed a significant improvement in the mean total scores of the BNSS and PANSS (at baseline (T0) vs five years (T3)). The improvement was also in some negative subscales (PANSS Negative Factor subscale) but not in others and the Epitrack tool. The overall results showed that clozapine is a useful therapeutic tool that does not affect the cognitive decline of these patients.

The Role of Fatigue and Satisfaction of Compassion, and Hopelessness in Healthcare Workers in the Alzheimer's Disease in the Post-COVID-19 Pandemic.

The COVID-19 pandemic has left emotional consequences for healthcare workers. Dramatic results are obtained on compassion fatigue, burnout, and hopelessness in healthcare workers (HCWs) of older adults with Alzheimer's disease. Our study evaluated differences in these factors during and after the pandemic in 48 HCWs. The results showed a statistically significant difference in the Satisfaction of Compassion (P=0.014; during vs post-pandemic) and in the subscale of Secondary Trauma (P=0.005) and Burnout (P=0.49) in CFSS. The results were not statistically significant on the BHS scale (P=0.285). However, hopelessness was found in a higher percentage of HCWs at the end of the pandemic than during the pandemic period (respectively: 35.67% vs 31.67%).

Neuronetwork Approach in the Early Diagnosis of Depression.

BACKGROUND: Depression is a common mental illness, with around 280 million people suffering from depression worldwide. At present, the main way to quantify the severity of depression is through psychometric scales, which entail subjectivity on the part of both patient and clinician. In the last few years, deep (machine) learning is emerging as a more objective approach for measuring depression severity. We now investigate how neural networks might serve for the early diagnosis of depression. SUBJECTS AND METHODS: We searched Medline (Pubmed) for articles published up to June 1, 2023. The search term included Depression AND Diagnostics AND Artificial Intelligence. We did not search for depression studies of machine learning other than neural networks, and selected only those papers attesting to diagnosis or screening for depression. RESULTS: Fifty-four papers met our criteria, among which 14 using facial expression recordings, 14 using EEG, 5 using fMRI, and 5 using audio speech recording analysis, whereas 6 used multimodality approach, two were the text analysis studies, and 8 used other methods. CONCLUSIONS: Research methodologies include both audio and video recordings of clinical interviews, task performance, including their subsequent conversion into text, and resting state studies (EEG, MRI, fMRI). Convolutional neural networks (CNN), including 3D-CNN and 2D-CNN, can obtain diagnostic data from the videos of the facial area. Deep learning in relation to EEG signals is the most commonly used CNN. fMRI approaches use graph convolutional networks and 3D-CNN with voxel connectivity, whereas the text analyses use CNNs, including LSTM (long/short-term memory). Audio recordings are analyzed by a hybrid CNN and support vector machine model. Neural networks are used to analyze biomaterials, gait, polysomnography, ECG, data from wrist wearable devices, and present illness history records. Multimodality studies analyze the fusion of audio features with visual and textual features using LSTM and CNN architectures, a temporal convolutional network, or a recurrent neural network. The accuracy of different hybrid and multimodality models is 78-99%, relative to the standard clinical diagnoses.

Mood Disorders and Type of Work: What Interaction? An Italian study.

Very often we talk about interference of work activities with the onset of mood disorders: thinking of work as a potential protracted stressful event that can interfere with the mood balance of the population. It emerges from this study, with 1140 patients evaluated in 18 years, that there is no particularly stressful work (or non-work) activity which induces predominantly the onset of an acute phase of a mood disorder.

The Listening Experience in a Group of Adolescents with Mood Disorders.

At the Istituto Superiore "Grazio Cossali" secondary school in Orzinuovi (Brescia province) for COVID-19 pandemic emergency, and active listening project through individual and group counselling was proposed. Seven sample classes were selected for which a questionnaire was specifically designed, the students (male and female) were between the ages of 14 and 18. From the results of the questionnaire and the clinical observation, a part of the students show mood disorders with depression type symptoms, attention and concentration difficulties, decrease in academic performance, difficulty in managing emotions, irritability, behavioural fidgeting, displays of anxiety. Furthermore, the individual listening desk was set up to which all the students at the school had access. The primary objective of the project was that of improving emotional, relationship and behavioural issues. Several methodologies were used, such as: participant observation, brainstorming, psychoeducation, active listening, communicative feedback, reactivation of resources. From the active listening carried out in group and individually, the emotional awareness triggered an improvement in the ability to manage emotions in the student, reactivating their own personal resources and improving mood.

Emergency, Fear, Worry and Intolerance of Emotion.

The emerging worry from emergency situations transforms into pervasive worry in some people, this due to its intensity, duration and intrusiveness, which significantly interferes with daily life. From the emotion of emergency, fear, through repetitive thought forms, we focus on worry. Its characteristics and underlying meta-beliefs are briefly analysed. Worrying exacerbates negative emotions and for many patients the feeling of not being able to tolerate the anxiety and anguish resulting from constant brooding. Brief hints of therapy are proposed, useful for intervening in these forms of pathological worry.

Hope in Psychiatric Patients: An Observational Study in a Psychiatric Rehabilitation Centre.

INTRODUCTION: The COVID-19 pandemic has led to the re-evaluation of some fundamental aspects for the management of emotions and psychological dynamics. Hope and its lack are important factors that have been especially evaluated in caregivers and HCWs. Instead, our study aimed to explore hopelessness among psychiatric rehabilitation center residents with Primary Psychosis. METHODS: We recruited 116 inpatients affected by Primary Psychosis (schizophrenia, bipolar disorder, major depression disorder and personality disorder). Hopelessness was sought through the BHS, during the covid-19 pandemic period. They were compared with data from previous studies on HCWs (HealthCare Workers), in the same period, and in the same centre. RESULTS: The results obtained in this group of patients showed high total scores on the BHS scale (mean total score: 7.28±SD 3.73). These data are significantly higher than those found in HWs in the same pandemic period (mean total score: 3.74±SD 3.62). Among the different disorders the borderline personality disorder patients have presented the highest score (mean total score: 8.00±SD 3.50). CONCLUSION: Understanding resident - and HCWs- level variations in hopelessness may be important for targeting interventions to improve the outcome of residential psychiatric patients.

Metabolic Alterations and Drug Interactions: The Role of the Association between Antipsychotics / Mood Stabilizers and Cognitive Deficits.

Alterations in the metabolic profile are one of the main consequences of the use of drug therapies in psychiatric patients. In particular, dysfunction of the metabolic profile (lipid and glycidic) is very frequent in patients taking antipsychotics, especially second-generation ones, and antidepressants. Similar alterations, albeit, to a lesser extent, were highlighted with the use of mood stabilizers. There are some clinical conditions in which clinicians add antipsychotics and mood stabilizers. Our study analyzed this interaction in 116 inpatients. Data showed an overall increase in metabolic parameters in all patients analyzed. However, no statistically significant differences were found in some subgroups of patients. The correlation between metabolic alterations and cognitive dysfunctions in these patients was also analyzed (not statistically significant).

Cryptogenic Stroke In The Context of Pandemic-Related Stress: The Role of Arterial Hemodynamics.

BACKGROUND: Up to 45% of ischemic strokes are cryptogenic, which is an impediment to proposing preventative measures. In this investigation we aimed to study underlying heart arrhythmias in patients with cryptogenic stroke, taking into consideration the context of the COVID-19 pandemic and stressful lockdown conditions. SUBJECTS AND METHODS: In this cross-sectional study we observed 52 patients with cryptogenic stroke >1 month after acute presentation, and a control group consisting of 88 patients without stroke. All patients undewent the laboratory and instrumental investigation consisting of the following: lipid spectrum; hemostasiograms; hemoglobin A1c; transthoracic or/and transesophageal echocardiography; 24-hours monitoring of ECG; computer tomography or magnetic resonance imaging of the brain. We studied the hemodynamics of the common carotid arteries using Doppler ultrasound imaging and digital sphygmography (SG). RESULTS: The groups were indentical with respect to the preponderance of study parameters (sex, age, comorbidities, instrumental and laboratory data). The ischemic stroke group had a statistically significant difference in the prevalence of the first type of extrasystolic arrhythmia according to our gradation of extrasystoles, which are ventricular systoles of extrasystolic contraction appearing before the transmitral blood flow peak (peak E in echocardiography). We observed that earlier ventricular systoles of extrasystole in the cardiac cycle predicted for greater growth of hemodynamic and kinetic parameters. Calculating the indices of a four-field table established the significant relationship between the moment of appearance of extrasystolic ventricular contraction in the cardiac cycle and the risk for cryptogenic stroke (normalized value of the Pearson coefficient (C`) of the two paramaters was 0.318). CONCLUSIONS: Extrasystolic arrhythmia appeared as an additional risk factor of earlier stroke. The most dangerous type of arrhythmia was when the ventricular contraction of the extrasystole appeared before the transmitral blood flow peak in the cardiac cycle. This observation could present a risk-marker for brain-related cardiovascular complications such as stroke, which might be patients suffering from different internal diseases, especially in the context of environmental stress conditions of the current pandemic and its related lockdown measures.

Mixed States: Diagnosis, Assessment and Diagnostic Stability.

Psychiatric disorders are among the top causes worldwide of disease burden and disability. A major criterion for validating diagnoses is stability over time. In our clinical practice, we noticed a diagnostic stability using assessment to early identify mixed feaures. Mixed states are often underdiagnosed, with important consequences in terms of worsening prognosis, frequent admission to the hospital, higher suicide risk and poorer quality of life. In order to be diagnosed with the new specifier in the case of major depression/maniac, the new DSM-5 specifier will require the presence of at least three manic/hypomanic symptoms (or depressive in case of maniac episode) that don't overlap with symptoms of major depression. For this reason, we analyzed retrospectively data from patients admitted in the Psychiatric Hospital from January 1st to December 31th 2021 to identify clinical features of the mixed states by administering the G.T.-MSRS scale. Within the 691 subjects of the sample, the large majority (74% of man and 76% of women) met criteria for mixed state; of those only about 34% of man and 31% of women were discharged with a diagnosis of Affective Disorder, however 70% in both man and women were prescribed a mood stabilizer. This study shows that there is a high prevalence of mixed states in the inpatient unit admission, which is demonstrated both from the prescription of mood stabilizers, and confirmed by the diagnosis of mixed states rated with the scale. The scale can be a useful instrument to detect early in the course if the hospitalization the presence of mixed state, in order to guide a tailored psychopharmacological treatment, and improve prognosis.

Educational Initiative about the COVID-19 Pandemic-Related Neuropsychiatry for Early Career Professionals in EU: The Impact of the Novel Virus on Brain, Mind, and Society.

BACKGROUND: The COVID-19 pandemic brought challenges to governments, healthcare systems (including, mental healthcare services), clinicians and researchers in the EU and worldwide. A range of neurological (e.g., brain fog, encephalitis, myalgia) and psychiatric (e.g., affective disorders, delirium, cognitive disturbances) complications of a novel nature have been observed in patients during the acute phase of illness, which often persist as a Long-COVID state for months after the primary recovery. The pandemic has progressed to a psychodemic and syndemic, affecting communities with social distress, panic, fears, increased home violence, and protest movements that derive from conspiracy theories and hostile attitudes towards vaccination and lockdown measures. In response to this complex scenario of major social changes, universities must face the need to equip the new generation of doctors with novel special skills. SUBJECTS AND METHODS: The study course (50 hours duration; 20 lectures, three webinars, three e-discussion forums, five local seminars, two social events, three intermediate assessments and a final test for certification; bilingual Russian/English hybrid format, information materials, video-content, interactive web-page and social media) was developed by the team of the International Centre for Education and Research in Neuropsychiatry (ICERN), and is unique for the EU. The course integrates the most relevant data on SARS-Cov-2-related neuropsychiatry, and COVID-19' pandemic impact on mental health and society, including assignment of the vulnerable groups of students and healthcare professionals. The major topics covered during the course are (i) Novel virus, (ii) Brain, (iii) Society. The project takes place originally in Samara State Medical University. The ICERN Faculty includes academic staff from France, Hungary, Italy, Russia, Switzerland, invited speakers from the WHO Regional Office for Europe and World Psychiatric Association (EU Zones) members, some of them employed at ICERN by remote work contracts. The format of the educational process for students is hybrid suggesting both remote and face-to-face events. Distant learning participants and EU lecturers are to attend on-line via zoom platform, whereas local participants and staff work face-to-face in the ICERN video-conference room. The course is addressed to a broad audience of doctors, undergraduate and postgraduate students, and researchers from EU wishing to upgrade their knowledge in the pandemic-associated neuropsychiatry. RESULTS: The evaluation process supposes three intermediate assessments and a final test for certification. On-line assessment is to be performed at the project web-page - 10 randomly selected questions with scoring from 1 to 10 each. The Pass Score is 70-100. At the end of the course all the participants receive certificates of Samara State Medical University according to the ERASMUS policy book, as planned in 2021. CONCLUSIONS: We formatted this course as essential for the target audience to improve their resources of professional adaptability in the field of neuropsychiatry and mental healthcare management during challenging times. The ICERN course in pandemic-related neuropsychiatry is essential for early career health professionals and targets the principles of "academia without borders" in the context of international medical knowledge exchange. In the conditions of the changing social situation this educational content is necessary for the young doctors to acquire the add-on skills on flexibility to switch toward new professional approaches in the times of need. The long-term outcomes in pandemic-related neuropsychiatry are still to be seen, though the first feedback on the course content is already promising for the academic community.

Virtual Reality-Based Interventions for Treating Depression in the Context of COVID-19 Pandemic: Inducing the Proficit in Positive Emotions as a Key Concept of Recovery and a Path Back to Normality.

BACKGROUND: During the COVID-19 pandemic as much as 40% of the global population reported deterioration in depressive mood, whereas 26% experienced increased need for emotional support. At the same time, the availability of on-site psychiatric care declined drastically because of the COVID-19 preventive social restriction measures. To address this shortfall, telepsychiatry assumes a greater role in mental health care services. Among various on-line treatment modalities, immersive virtual reality (VR) environments provide an important resource for adjusting the emotional state in people living with depression. Therefore, we reviewed the literature on VR-based interventions for depression treatment during the COVID-19 pandemic. SUBJECTS AND METHODS: We searched the PubMed and Scopus databases, as well as the Internet, for full-length articles published during the period of 2020-2022 citing a set of following key words: "virtual reality", "depression", "COVID-19", as well as their terminological synonyms and word combinations. The inclusion criteria were: 1) the primary or secondary study objectives included the treatment of depressive states or symptoms; 2) the immersive VR intervention used a head-mounted display (HMD); 3) the article presented clinical study results and/or case reports 4) the study was urged by or took place during the COVID-19-associated lockdown period. RESULTS: Overall, 904 records were retrieved using the search strategy. Remarkably, only three studies and one case report satisfied all the inclusion criteria elaborated for the review. These studies included 155 participants: representatives of healthy population (n=40), a case report of a patient with major depressive disorder (n=1), patients with cognitive impairments (n=25), and COVID-19 patients who had survived from ICU treatment (n=89). The described interventions used immersive VR scenarios, in combination with other treatment techniques, and targeted depression. The most robust effect, which the VR-based approach had demonstrated, was an immediate post-intervention improvement in mood and the reduction of depressive symptoms in healthy population. However, studies showed no significant findings in relation to both short-term effectiveness in treatment of depression and primary prevention of depressive symptoms. Also, safety issues were identified, such as: three participants developed mild adverse events (e.g., headache, "giddiness", and VR misuse behavior), and three cases of discomfort related to wearing a VR device were registered. CONCLUSIONS: There has been a lack of appropriately designed clinical trials of the VR-based interventions for depression since the onset of the COVID-19 pandemic. Moreover, all these studies had substantial limitations due to the imprecise study design, small sample size, and minor safety issues, that did not allow us making meaningful judgments and conclude regarding the efficacy of VR in the treatment of depression, taking into account those investigations we have retrieved upon the inclusion criteria of our particularistic review design. This may call for randomized, prospective studies of the short-term and long-lasting effect of VR modalities in managing negative affectivity (sadness, anxiety, anhedonia, self-guilt, ignorance) and inducing positive affectivity (feeling of happiness, joy, motivation, self-confidence, viability) in patients suffering from clinical depression.

From the Temperaments to the Bipolar Mixed States: Essential Steps for the Clinicians on Understanding The Mixity.

The notion of "mixity" of the dysphoric phases of the bipolarity includes the most insidious symptoms of the bipolar spectrum of mood disorders: the overlapping between depression-restlessness-irritability-grief-tension-anxiety can cause worsening of the mood disorders and in the most acute phases may cause increased risk of major behavioural disruption including murder and suicide. The "mixity" is a dynamic notion describing the presence of overlapping symptoms of mixed states, in an increasing intensity level. The early utilization of the rating scale on mixed states, "GT-MSRS", which can demonstrate the level of "mixity" of the mood disorder, can prevent this. Mixed states occur in an average of 40% of bipolar patients over a lifetime;when considering bipolarity the notion of the "mixity" becomes the conceptual reference point of the diagnostic process.

Psychomotor Agitation and Mood Disorders in Patients with Intellectual Disabilities: Efficacy of Treatment with Mood Regulators.

The frameworks of impulsivity and temperamental irritability of people with intellectual disabilities, presenting disabilities both for organic cause, e.g. postpartum, and for congenital mental retardation, may often present impulse control disorders, irritability and psychomotor restlessness, busyness and insomnia, from likely non-epileptic neuronal dysfunction. The patients with intellectual disabilities presenting mood disorders need to be treated with a therapy similar to that of other patients with mood disorders in the bipolar spectrum (namely predominantly with mood regulators), even if they are not mood pathologies classifiable as the others of the bipolar spectrum disorders: we can call them "abnormal mood disorders".

Loneliness and Hopelesness: Their Role in the Depressive Cases during the COVID Pandemia.

The COVID-19 pandemic has created new problems and presented new challenges for its management. Hope, or rather its absence, social isolation and loneliness are considered risk factors for the development of anxious and depressive symptoms. Health authorities have had to address issues regarding the mental health risks that the pandemic has created. There is numerous scientific evidences of the increase in affective disorders in the last two years. Associated with these disorders, particular characteristics of personality temperament, such as affective temperament, can determine an increased risk especially in some patient populations, such as the elderly, with significant negative consequences on the quality of life and on the onset of mental and organic diseases. The hope of the end of the pandemic has been placed on mass vaccination. After an initial enthusiasm there was a growing concern about its side effects. An adequate information policy is necessary to put an end to concerns about vaccines and thus lead to an increase in hope for the future and an end to social isolation.

The Effect of the Pandemic on the Care of Patients with Mental Disorders: Measure of "Compassion Fatigue" and "Burn-Out" in the Operator.

BACKGROUND: The Covid-19 Pandemic has had a significant impact on psychophysical well-being and the ability to work productively in contexts concerning people's physical and mental care. The helping professions involved have seen an increase in stress levels, a sense of helplessness, fear, pain and social isolation. They are anchored to the hope of being able to return to their normality. METHOD: In this study, 87 mental health operators were evaluated, divided into nurses, psychiatric rehabilitation technicians, educators, social workers, psychologists and doctors, working in two psychiatric care rehabilitation communities in Puglia and Campania in southern Italy. RESULTS: The results obtained with the administration of the scales ProQOL, BHS, Save-9, BDI-II, BEES reported a remarkable impact in nursing and medical professions due to the pandemic. A 11%. burn-out was reported by nurses. CONCLUSIONS: The collected data are comparable to the previous work (Franza et al. 2015, 2020); however, there is no evidence of a high level of burnout in the helping professions involved in this study.

The Emotional Impact of the Operator in the Care of Patients With Mental Disorders during the Pandemic: Measure of Interventions on Compassion Fatigue and Burn-Out.

BACKGROUND: The continuation of the health emergency due to the management of COVID-19 is having a profound effect on all aspects of society, including mental health and physical health. This observational study examined practitioners of psychiatric rehabilitation and therapeutic communities, focusing on the emotional aspects of patient care, in particular the fatigue of compassion, empathy and lack of hope, aspects that could be directly linked to the burnout of health professionals, as found in other similar studies. METHOD: In this study, self-administered scale data was collected in 87 healthcare professionals recruited from 3 different psychiatric rehabilitation communities. In particular, we assessed the fatigue of compassion, vicarious trauma, burnout and hope (hopeless), empathy and depressive symptoms in the two months of May and June 2021. RESULTS: The results obtained after the administration of the following rating scales, ProQOL, BHS, SAVE-9, BDI-II and BEES, showed an overall increase in scores in all professional figures, a significant fatigue of compassion, while the percentage burnout is not present in several groups. The presence of high levels of hope, satisfaction of compassion is indicative of a moderate level of empathy in some professional figures; these high levels can protect workers from the risk of developing work-related stress and depressive symptoms. CONCLUSIONS: The data obtained with this study are not similar to those of previous studies, although they may indicate the importance of factors such as hope, empathy in the care of the patient with psychic disorders in rehabilitation communities, underlining the need for interventions aimed at the emotional management of the care relationship as a tool to improve care and prevent burnout even during times of high stress, such as managing a pandemic.

The Connection between Bipolar Spectrum Disorders and Eating Disorders.

The bipolar spectrum of mood, in its broadest sense that includes all kinds of mood instability, presents various symptoms related to instability and mood swing, including symptoms and manifestations of "mixed states" (the symptoms of "mixity") and symptoms of eating disorders (ED). It is essential not to forget that depression itself is only "a phase" of the wider bipolar spectrum of mood, which therefore remains the pathology to be treated adequately with a polytherapy composed by mood regulators and antidepressants. "Mixed" symptoms (including symptoms of eating disorders), if not properly treated, can subtly enter the patient's life, leading to a worsening of the clinical picture to a clear chronicity.