Background: Bipolar depression accounts for most of the disease duration in type I and type II bipolar disorder (BD), with few treatment options, often poorly tolerated. Many individuals do not respond to first-line therapeutic options, resulting in treatment-resistant bipolar depression (B-TRD). Esketamine, the S-enantiomer of ketamine, has recently been approved for treatment-resistant depression (TRD), but no data are available on its use in B-TRD. Objectives: To compare the efficacy of esketamine in two samples of unipolar and bipolar TRD, providing preliminary indications of its effectiveness in B-TRD. Secondary outcomes included the evaluation of the safety and tolerability of esketamine in B-TRD, focusing on the average risk of an affective switch. Methods: Thirty-five B-TRD subjects treated with esketamine nasal spray were enrolled and compared with 35 TRD patients. Anamnestic data and psychometric assessments (Montgomery-Asberg Depression Rating Scale/MADRS, Hamiltondepression scale/HAM-D, Hamilton-anxiety scale/HAM-A) were collected at baseline (T0), at one month (T1), and three months (T2) follow up.Results: A significant reduction in depressive symptoms was found at T1 and T2 compared to T0, with no significant differences in response or remission rates between subjects with B-TRD and TRD. Esketamine showed a greater anxiolytic action in subjects with B-TRD than in those with TRD. Improvement in depressive symptoms was not associated with treatment-emergent affective switch. Conclusions:Our results supported the effectiveness and tolerability of esketamine in a real-world population of subjects with B-TRD. The low risk of manic switch in B-TRD patients confirmed the safety of this treatment.

Importance Evidence emerged concerning how inflammatory arthritis and mood disorders can often occur in the same patient and show a similar clinical pattern. An overview of the rheumatological and psychiatric aspects of these diseases can certainly be useful for the improvement of patients' clinical and therapeutic management. Objective The aim of this narrative review was to summarize existing literature about common pathogenetic and clinical aspects as a means of improving management and therapeutic approach in patients affected by rheumatoid arthritis, psoriatic arthritis and spondyloarthritis. Outcomes such as disease activity indexes and patient reported outcomes (PROs) were considered. Findings Common pathogenetic pathways emerged between inflammatory arthritis and mood disorders. Pro-inflammatory mechanisms, such as TNFα, IL-6, IL-17 and oxidative stress factors as well as neurotransmitter alterations at the level of CNS and blood–brain barrier (BBB) cells are involved. The activation of these common pathogenetic pathways is, also, affected by the same triggers, such as smoking, stress, lifestyle, and evidence has emerged concerning the possibility of the clinical efficacy of using the same therapeutic approaches. Conclusions The main causes of the variability in clinical studies outcomes are the rheumatological diseases considered, the prevalence of depression in the general population and in patients with rheumatological diseases and the type of depressive symptom examined. Patients affected by inflammatory arthritis can present symptoms and signs in common with mood disorders, leading to possible clinical overlap. There are still few studies analyzing this concept: they are extremely heterogeneous, both in the characteristics of the population taken into consideration and in the methods used for the definition of depressive disorder, but the suggestions of the data obtained so far are promising and deserve to be pursued.

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Background: The Covid 19 pandemic might have impacted response to drug treatment in major depressive episode (MDE). We compared responses to three different antidepressant drugs, i.e., vortioxetine, sertraline, and trazodone, in outpatients with MDE during Major Depressive Disorder (MDD), Bipolar Disorder (BD), or schizophrenia and related psychoses (SSOPDs) during two time periods, i.e., prior to suffering Covid-19–related trauma and after suffering such trauma. Methods: We conducted an observational study on clinically stabilised for at least 6 months outpatients with MDE during the course of MDD (N=58), BD (N=33), or SSOPDs (N=51). Patients, whose baseline assessments of Montgomery-Åsberg Rating Scale (MADRS), Hamilton Anxiety Rating Scale (Ham-A), Brief Psychiatric Rating Scale (BPRS), Visual Analogue Scale for Craving (VAS-crav) and World Health Organization Quality of Life, Brief version (WHOQOL-BREF) were available, were recruited at the time they suffered Covid-19–related traumas. Fifty patients, prior to the pandemic, when they were clinically stable, were treated with 15 mg/die vortioxetine, 44 with 450 mg/die trazodone, and 48 with 150 mg/die sertraline. After experiencing a major Covid-19–related personal trauma, patients showed clinical worsening which required dosage adjustment (20 mg/day vortioxetine; 600 mg/day trazodone, and 200 mg/day sertraline) and, for a part of them, a month of hospitalisation. Scores on the MADRS, Ham-A, BPRS, VAS-crav and WHOQOL-BREF were compared drug-wise and gender-wise with Student’s t test for continuous variables and χ2 for categorical variables. Result: The sample consisted of 142 outpatients (age, mean 39.63 ± 16.84; 70 men and 72 women); women were older than men (mean age 43.18 ± 17.61 vs. 35.98 ± 15.30; p=0.01). The two genders did not differ on other variables). For all treatments, symptoms worsening was observed at the time of trauma, followed by slow recovery with treatment readjustment. Trauma-related worsening in patients on vortioxetine was less intense than patients on the other two antidepressants and recovery was faster. All drugs were associated with an improvement in QoL. The vortioxetine group showed a lower hospitalisation rate (24%) than sertraline (35.4%) and trazodone (38.6%), but this was not significant (p=0.27). Conclusion: All drugs improved symptoms after Covid-19 trauma in patients with MDE, with vortioxetine showing a small advantage. No differences between vortioxetine, sertraline and trazodone were found as concerns the need for hospitalisation.

Background: Major Depressive Episodes (MDEs) may characterise many psychiatric disorders. Its pharmacotherapy is laid with unmet needs, rendering the testing of new drugs necessary. Objective: To compare the effects of vortioxetine with those of other antidepressants (OADs) in a 1-year naturalistic setting. Methods: We included 126 adult patients with a MDE in the course of major depressive (MDD), bipolar (BD), or schizophrenia spectrum disorders (SSOPDs), with or without substance use disorder (SUD), who received 5-20 mg/day oral vortioxetine, and compared them with 100 patients receiving OADs at baseline and after 1, 3, 8, and 12 months on their scores on the MADRS, the CGI-S, the 24-item BPRS, the YMRS, the Hamilton Anxiety Rating Scale, a Visual Analogue Scale for craving, the Columbia-Suicide Severity Rating Scale, and the WHOQOL-BREF. Results: Patients on vortioxetine improved similarly to those on OADs on all measures, independently from having or not a comorbid SUD. However, they improved with time better than their OADs counterparts if affected by BD or SSOPDs, but not MDD, on the CGI-S, BPRS depression, anxiety, and manic symptoms. SUD hampered the response of anxiety to treatment. Men improved on depression with time better than women. Conclusion: MDEs responded to vortioxetine similarly to OADs by improving in depression general psychopathology, anxiety, suicidal thinking, and quality-of-life, independently from SUD comorbidity. MDEs of patients with BD or SSOPDs on vortioxetine responded better than that of patients on OADs.

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Background:Psoriatic Arthritis (PsA) is a chronic inflammatory disease characterized by a condition of inflammation of joint and periarticular tissues with progressive destruction of bone and cartilage tissues and consequent disability. Numerous studies suggest that the systemic inflammation that characterizes this disease is the basis of the onset of numerous comorbidities, including anxiety and depression.Objectives:This prospective study aims to examine the psychometric profile of patients with chronic inflammatory arthritis to investigate possible correlations with psychiatric comorbidities and disease status.Methods:from October 2018 to March 2019, consecutive out-patients with PsA (according to CASPAR criteria) referred to the Rheumatology Unit of the University of Rome Tor Vergata, were evaluated by a dedicated psychiatrist for attachment style (Relationship Questionnaire - RQ), alexithymia (Toronto Alexithymia Scale - TAS20), perceived stress (Perceived Stress Scale - PSS) and depressive symptoms (Beck Depression Inventory - BDI). These indices were then correlated with clinimetric indices, indices of inflammation and therapy taken by the patient. Statistical analysis was performed using Fisher’s exact test and Pearson’s correlation coefficient.Results:33 patients affected by PsA and 40 healthy individuals as control group were enrolled. The RQ test showed that in patients an insecure “avoidant” attachment style prevails (51.5%) compared to the control group (10%) (p<0.0008)[Figure 1]. This result correlates with the presence of alexithymia and with the duration of illness, showing that patients with an “insecure” profile at the RQ test are those who have higher scores on the TAS-20 scale (p=0.035) and a longer duration of illness (p<0.0001). Regarding the perception of stress, at the PSS test women have mean values (18.12±7.31) statistically superior to the values of the male population (11.69±7.79)(p=0.0015). PSS values of the overall study population were directly proportional to RQ values (p<0.0068) and TAS-20 values (p<0.0001). The correlation between PSS and TAS-20 was further confirmed in the analysis of the individual subgroups “patients” (p<0.0001) and control group (p<0.0001)[Figure 2]. No correlation was shown with phlogosis and clinimetric indices.Conclusion:This study suggests how PsA patients are a more vulnerable subtype of patient from the psychological point of view, with an avoidant attachment style, characterized by the difficulty to express emotions and to rely on others in times of need. These characteristics can influence the adherence to pharmacological therapies and the doctor-patient relationship. This profile is manifested more frequently in female patients, with long duration of illness, high perception of stress. The state of disease activity does not influence these elements, suggesting that the insecure attachment style is not related to the single inflammatory flare, but is the result of years of illness and long-standing disease. Our results support the relevance of early diagnosis in PsA.Disclosure of Interests:None declared

Motivated behaviours are thought to lead to enhanced performances. In the neurorehabilitation field, motivation has been demonstrated to be a link between cognition and motor performance, therefore playing an important role upon rehabilitation outcome determining factors. While motivation-enhancing interventions have been frequently investigated, a common and reliable motivation assessment strategy has not been established yet. This review aims to systematically explore and provide a comparison among the existing motivation assessment tools concerning stroke rehabilitation. For this purpose, a literature search (PubMed and Google Scholar) was performed, using the following Medical Subject Headings terms: “assessment” OR “scale” AND “motivation” AND “stroke” AND “rehabilitation”. In all, 31 randomized clinical trials and 15 clinical trials were examined. The existing assessment tools can be grouped into two categories: the first mirroring the trade-off between patients and rehabilitation, the latter reflecting the link between patients and interventions. Furthermore, we presented assessment tools which reflect participation level or apathy, as an indirect index of motivation. In conclusion, we are left to put forth a possible common motivation assessment strategy, which might provide valuable incentive to investigate in future research.