The results of the meta-analysis showed a potential protective effect of PA on prevalent and incident depression.Depression is a major contributor to the overall global burden of disease, with high prevalence and relapse rate. Several factors have been considered in order to reduce the depression burden. Among them, physical activity (PA) showed a potential protective role. However, evidence is contrasting probably because of the differences in PA measurement. The aim of this systematic review with meta-analysis is to assess the association between objectively measured PA and incident and prevalent depression. The systematic review was conducted according to methods recommended by the Cochrane Collaboration and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant papers published through 31 August 2019 were identified searching through the electronic databases PubMed/MEDLINE, Excerpta Medica dataBASE (Embase), PsycINFO, Scopus, Web of Science (WoS), and the Cochrane Library. All analyses were conducted using ProMeta3. Finally, 42 studies met inclusion criteria. The overall Effect size (ES) of depression for the highest vs. the lowest level of PA was −1.16 [,  Depression is one of the major leading causes of disability worldwide, affecting approximately 400 million people , with 9%Current studies are focusing on the important role played by lifestyles and in particular physical activity (PA), in both preventing and treating depression . SeveralTwo recent meta-analyses focusing on prevalent depression and incident depression found an inverse association between prevalent depression and PA , while tWe performed a systematic review with meta-analysis of the evidence from the literature to assess the relation between physical activity objectively measured and incident and prevalent depression.https://www.crd.york.ac.uk/prospero/).We conducted this systematic review according to the methods recommended by the Cochrane Collaboration  and to tStudies were identified searching through the electronic databases PubMed/MEDLINE, Embase, Scopus, Web of Science (WoS), PsycINFO and the Cochrane Library. We combined the search strategy of free text terms and exploded MESH headings for the topics of depression, physical activity, objective measurements, and type of study. The strategy was firstly developed in PubMed/MEDLINE and then adapted for use in the other databases . StudiesWe considered studies that investigated the relation between physical activity objectively measured and depression, both as a continuous and as a binary variable. Adult participants of both sexes were considered. As done before ,21, bothIdentified studies were independently reviewed for eligibility by two couples of authors  in a two-step process: a first screening was performed based on title and abstract, while full texts were retrieved for the second screening. At both stages disagreements by reviewers were resolved by consensus. Data were independently extracted by three authors  and supervised by a senior author (VG) using an ad-hoc developed data extraction spreadsheet. The data extraction spreadsheet was piloted on 10 randomly selected papers and modified accordingly. As done before ,24,25, bThe quality evaluation of the included publications were independently assessed by two authors using the New-Ottawa Scale  for obse®  software. Due to heterogeneity, a random effects meta-analysis was employed. In order to reduce the heterogeneity, two sensitivity analyses were conducted, considering the following items: (i) study design, (ii) participants’ comorbidities. Moreover, a subgroup analysis by gender was conducted in order to estimate potential different effects among the two groups. We assessed publication bias with the visual inspection of a funnel plot  based on 37,408 participants . A potential publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . However, the ES estimated did not change after the trim and fill method , icipants a, with hl method b.p-value < 0.001] based on 33,812 subjects. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering patients with chronic obstructive pulmonary disease (COPD), included 6 datasets, and the pooled ES was −1.08  based on 683 subjects. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering obese participants, included 5 datasets, and the pooled ES was −0.35  based on 1354 participants. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering participants with (any type of) cancer, included 5 datasets, and the pooled ES was −1.79  based on 955 participants. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test .The sub-group analysis considering only the general population (without diseases), included 21 datasets, and the pooled ES was −1.32  based on 34,764 participants. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering only cross-sectional analysis, included 27 datasets, and the pooled ES was −0.23  based on 17,191 participants. A high statistical heterogeneity was found . A publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering only cohort datasets, included 6 datasets, and the pooled ES was −2.61  based on 17,515 participants. High statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering only interventional studies , included 8 datasets, and the pooled ES was −2.63  based on 2644 participants. High statistical heterogeneity was found . Potential publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test .The sub-group analysis considering only observational studies , included 34 datasets, and the pooled ES was −0.99  based on 1415 participants. High statistical heterogeneity was found . Potential publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test . The sub-group analysis considering only men, included three datasets, and the pooled ES was −0.11  based on 928 participants. A high statistical heterogeneity was found . However, no publication bias was found by the visual assessment of the funnel plot and confirmed by the Egger’s linear regression test .Considering The sub-group analysis considering only women, included seven datasets, and the pooled ES was −1.91  while, in the subgroup analysis including only cross-sectional datasets, the risk of prevalent depression was estimated on 17,191 participants and the ES was −0.23 . In subgroup analysis including only longitudinal datasets, the risk of incident depression, estimated on 17,515 participants, was lower −2.61 [.The current systematic review with meta-analysis—which included 43 studies in qualitative evaluation and 42 studies in the quantitative analysis—provided data on the association between objectively measured PA and the risk of depression. Since some studies expressed data separated for gender, a total of 42 datasets have been considered. The pooled ES based on 37,408 subjects indicated a significantly protective effect of PA on depression [−1.16 , With the purpose of deeply understanding the strength of the association between objectively measured PA and depression, a sub-group analysis by participants’ comorbidity has been conducted. When studies assessing the association among participants with comorbidities were considered, the ES were not statistically significant (apart for COPD participants). However, prescription of adapted PA among participants affected by co-morbidities should be considered . To the These results are extremely important considering that depression is one of the leading causes of disabilities worldwide . In the 2 remained extremely high. However, a I2 value higher than 90% means that heterogeneity is directly due to heterogeneity among studies, instead of sampling error [2 [In the last decades, several studies have shown that a healthy lifestyle, in particular the intensity and length of physical activity ,73, are ng error . Moreoveerror [2 . Another2 value that might reduce the generalizability of our results. Most studies are observational and based on cross-sectional analysis. Nevertheless, we performed sensitivity analyses only including trials and longitudinal studies, increasing the robustness of our results. Due to the high heterogeneity in reporting the level of PA performed by participants in original studies, it was not possible to identify a recommended level of PA. The inability to estimate an association between severity of depression and PA is another important limitation. The main strengths of this review are being systematic in nature and its comprehensive way to include the entire scientific evidence published so far on the main medical-scientific databases. Furthermore, the pooled ES was significantly large, based on 37,408 participants, and sub-group analyses have been conducted based on participants’ comorbidity and study design. In the primary studies, diagnosis of depression was consistently based on the DSM criteria and was established by trained investigators using validated assessment scales mainly with interrater reliability.The main limitation of this systematic review is the high ITo conclude, the results of this systematic review and meta-analysis clearly show a statistically significant protective effect of objectively measured PA on prevalent and incident depression. An increased PA is associated with lower risk of depression. The advantages of our study are several. Firstly, this study offers a systematic overview of previous studies assessing objectively measured PA and depression. Secondly, this study highlights the usefulness of objectively measured PA compared to self-reported one. Objectively measured PA is not only more precise in estimating duration, total amount, and intensity of PA, but indirectly it can also better strengths the association with some diseases, as depression. Thirdly, this study shows the importance to promote physical activity forasmuch it can help to reduce the high burden of depression in our society. Lastly, our findings are relevant for both policy makers and clinicians as physical activity is one of the cheapest, non-pharmacological treatment that might be prescribed to the general population with potentially major public health impact. Physical activity is important across ages and should be integrated into daily life.


Rotary drilling for oil and natural gas uses drilling fluid for lubrication of the bit, to seal off unstable shale layers, and floating out rock cuttings. Drilling fluid is a water–clay chemical mixture. Produced water is a water–sand chemical mixture. Land farming is a common disposal technique of drilling fluid and produced water. In the land farming process, amendments of fluid are repeatedly applied to the soil surface. Plant growth and soil chemical properties may be altered by additions of drilling fluid, because of alkalinity, salinity, trace elements, and petroleum residue contained in waste. The objective of this study was to determine the change in soil pH, electrical conductivity (EC), total nitrogen and carbon, and extractable nutrient levels following the land application of drilling fluid and produced water. The study was a comparison of three plots with similar soil properties and conditions. The three study plots had various levels of drilling fluid and produced water applications. The data show a major difference from field-to-field for EC, Na, and Cl levels. The EC and salt levels increased with additional applications of drilling fluid and produced water. The percent total nitrogen values and plant available P levels were very low in all fields. High EC and salt values, coupled with low N and P levels, would be detrimental to plant growth and development. To successfully vegetate this land-farm site, application of N and P fertilizer would be required. This study help to give a better understanding of practical ways to land-farm drilling fluid and produced water in a fashion that both minimizes environmental issues and is economically feasible in Arkansas. Thus, this research will provide important information for soil contamination management and contributes on understanding of the responses of soil properties to drilling fluid and produced water in the future. Increases in global petroleum and natural gas demand, coupled with new production technologies, have triggered increased rotary drilling to meet the world’s rising energy needs. Petroleum and gas wells are drilled in areas where it was not previously economically feasible. The United States is now the world’s largest oil producer. Rotary drilling is the common method of drilling implemented to reach petroleum and natural gas deposits ,2. In th− anion, which is very mobile in the soil and is subject to leaching. In high concentrations, however, chlorides will inhibit plant growth, and they are specifically toxic to some plants. Excessive levels of chlorides in the soil can result in chloride-sensitive crops accumulating excessive amounts. The major detrimental effect of chloride to plants is its contribution to osmotic stress caused by excessive salts in the root zone [The drilling fluid is generally a water-based mud containing mainly bentonite clay. Most drilling muds consist of aqueous slurry of 5% bentonite in amended with sodium hydroxide and a density-increased material such as barite, to help float out rock cuttings . The mudoot zone ,11. SeedThe volume of mud required to drill a hole is approximately three times the volume of the hole . After tThe State of Arkansas has restrictions on contaminant levels being applied to landfarm soil surfaces, not the build-up of soil contamination levels in the soil profile. The Arkansas Department of Environmental Quality (ADEQ) is the decision-making body for State of Arkansas’s environmental regulations. Implementation of such regulations can include restrictions, such as not allowing drilling fluid to soils that have any pooled water already at the soil’s surface and not allowing drilling fluid applications that would cause ponding ,17. WhenThe land farm in this study was located in Franklin County, 53 km east of Ft. Smith, AR. The coordinates of the site were 35°20′19.15″ N, 93° 56′46.34″ W. The study area, with a total area of 7.2 hectares, is in the western part of Arkansas . The ArkThe Natural Resources Conservation Service (NRCS) Soil Survey indicated Fields 1 and 2 was a Leadvale silt loam that consists of deep to very deep, moderately well drained soils with a fragipan . The soi2), it is inevitable to use all the same fluid in the study area. For this reason, we believe that the same fluids were used in each field. The fluids generally consists of water, sand, guar gum, petroleum distillate, and hydrochloric acid [A land farm used for disposal of freshwater and diesel contaminated drilling fluids and produced water is the focus for this study. Due to the fact that the study area is relatively small with an area of 7.2 hectare . Duplicate samples at locations 1A and 3D in After soil sampling was complete, samples were placed on ice in a cooler for transport back to the University of Arkansas at Fayetteville. Upon returning to the university, soil samples were air dried and ground using a mortar and pestle to pass a 2 mm sieve. Thirty-six samples were totally analyzed in the study area with a total area of 7.2 hectare (0.072 kmS) shows the variation of the read response versus concentration of sample. Prior to generating a final reports, the data is reviewed a second time. The second review includes a sensibility check and technical criteria.EPA Digestion Method 3050B was used to determine total P, K, Ca, Mg, S, Na, Fe, Mn, Zn, Cu, B, Al, Pb, Cr, Ni, and Ba. It is EPA’s selected analytical method for soil sample that is most widely applied in the US. The procedure comprises multiple cycles of high temperature digestion, evaporation, and cooling. Each digestion cycle the leachates were filtrated through 20 μm pore filter papers, diluted to 25 mL with ultrapure water, stored in 50 mL polypropylene centrifuge tubes, and refrigerated until compositional analysis. All samples were analyzed using Inductive Coupled Plasma–Atomic Emission Spectrometer (ICP-AES) at Soil Microbiology Laboratory and Agricultural Diagnostic Laboratory in the University of Arkansas, Fayetteville, USA . Upon coThere were two previous greenhouse studies associated with this landfarm site. An undergraduate research study was performed looking at “Using Soil Amendments to Increase Bermuda Grass Growth in Soil Contaminated with Hydraulic Fracturing Drilling Fluid” . This waBased on the results of this study, the addition of the recommended plant nutrients enhanced Bermuda grass growth. After the nine-week plant growth phase, soil EC and water-extractable Cl were greater in the 0–15 cm depth soil compared to the 0–30 cm depth for the respective vegetation treatments . They foSoil samples taken from a drained settling pond located on-site revealed many of the same characteristics as soil samples taken from fields on-site ,20. The Evidence of hydrocarbons was most evident in the areas furthest down-gradient. Field 3 soils were blackened, and hydrocarbon odor was noticed ,29. EC lThe percent total nitrogen values were low in Fields 1, 2, and 3, which is too low to promote optimum plant growth . Field sEPA digestion Method 3050B displaced Pb and As levels as undetectable in all field’s samples . Field aAll RPD values tested, except percent total N, fell under fifteen percent, which means that section composite samples were nearly uniform . In SectSoil analysis values varied largely within each field indicating that there was a large amount of variability between applications of drilling fluid and produced water. Mehlich 3 extractable sodium and chloride values in Field 3 ranged from 1344 to 2072 mg/kg and 1434 to 3026 mg/kg, respectively. EPA digestion Method 3050B values in Field 1 for iron and aluminum ranged from 20,895 to 26,618 mg/kg and 9140 to 12,960 mg/kg, respectively . AccuratComposite sampling was performed during a return trip to the site in January 2020 for Fields 1, 2, 3, and Control Samples East and West to look for textural variability between fields. The analysis for texture of samples from the site showed varied amounts of sand, silt, and clay between Fields 1, 2, and 3, and the two control samples . Fields The exploration of oil and natural gas requires the use of drilling fluids. Drilling fluids are the materials created for the purpose of drilling oil and natural gas wells. The fluids are pumped into the hole during the drilling process to help cool and lubricate the bit, suspend cuttings, seal the formation, and control well bore pressure. Drilling mud is continuously recycled to remove solids until it can no longer be utilized. After drilling is completed, the drilling fluid and mud in the reserve pit must be disposed of. Land application or land-farming is a generally accepted method of disposing of the contents of the reserve pit. It is a waste management practice in which oil and gas wastes are mixed with or applied to the land surface. Due to the increase in drilling in our study area, the need of drilling fluids through land application has increased . ConsequContamination of soil or water sources off-site appear to be highly unlikely. There was a 30-m wide buffer zone between Field 3 and Hurricane Creek, which consisted of native tall grasses, which should eliminate the possibility of contaminants moving down gradient and into the waterway. Baseline soil samples were not taken prior to the beginning of the land-farm process; this makes it difficult to speculate whether there was possible contamination that already existed on site as a result of natural processes. Nickel concentrations were normal in all fields with a mean of 14.97 mg/kg; soil ranges from 10 to 1000 mg/kg are normal.Drilling fluid applications to soil results in changes in soil chemical properties. These effects were most visibly apparent in Field 3; which was largely un-vegetated at the original time of sampling. The EC levels were highest in Field 3, where Na and Cl had accumulated in the surface soil over time; the effects were detrimental to the soil. Precipitation was needed to push salts leach into the soil profile. The total N and extractable P levels, which are essential nutrients for plant growth, were low in all fields. The previous sprigging of Bermuda grass, in 2009, by company employees was the appropriate method of vegetation establishment, but was not effective, probably because of lack of precipitation after sprigging and the timing of the event was late summer and field N and P levels were inadequate. The fields in the study needed precipitation, supplemented by irrigation, to promote plant growth; these fields were re-sprigged in Spring 2010.Site closure procedures requires vegetative coverage of 75% or more, or equivalent to the surrounding landscape, whichever is less, within six months of site closure. Arkansas does not have standard guidelines for allowable soil contaminant levels of land-farms. Instead the state uses standards set in Regulation 23 for the management of remediation and related wastes, usually arriving at a site-specific standard for each clean-up. There were elevated levels of Na, Cl, and Ba within each field; this is likely the result of over application, in addition to spreading fluids that exceeded allowable contaminant limits. After revegetation occurred, the land-farm was then decommissioned and used for agricultural purposes; hay farming and cattle grazing. Visual results of a return trip to the location, in January 2020, showed nearly complete vegetation coverage of Fields 1, 2, and 3. Previous remediation recommendations made were implemented to bring the location towards satisfactory vegetation levels and closure. A return trip occurred in January 2020 where nearly 100% vegetative cover was viewed. This research contributes on understanding of the responses of soil properties associated with energy developments in Arkansas. Therefore, this research can provide important information for soil contamination manager in making important decision and developing plans for use of the soil resources in the future.


M = 30.55; SD = 11.66) from countries in Latin America  and Europe , with a retrospective correlational cross-sectional design and a convenience sample. Participants were divided between demonstration participants  and non-demonstrators or followers who monitored participants through the media and social networks . Compared with non-demonstrators and with males, female and non-binary gender respondents had greater scores in mechanisms and criterion variables. Further random-effects model meta-analyses revealed that the perceived emotional synchrony was consistently associated with more proximal mechanisms, as well as with criterion variables. Finally, sequential moderation analyses showed that proposed mechanisms successfully mediated the effects of participation on every criterion variable. These results indicate that participation in 8M marches and demonstrations can be analyzed through the literature on collective rituals. As such, collective participation implies positive outcomes both individually and collectively, which are further reinforced through key psychological mechanisms, in line with a Durkheimian approach to collective rituals.8 March (8M), now known as International Women’s Day, is a day for feminist claims where demonstrations are organized in over 150 countries, with the participation of millions of women all around the world. These demonstrations can be viewed as collective rituals and thus focus attention on the processes that facilitate different psychosocial effects. This work aims to explore the mechanisms  involved in participation in the demonstrations of 8 March 2020, collective and ritualized feminist actions, and their correlates associated with personal well-being  and collective well-being , collective efficacy and collective growth, and behavioral intention to support the fight for women’s rights. To this end, a cross-cultural study was conducted with the participation of 2,854 people (age 18–79;  In this work, we aim to study the relationship between participation in the 8 March (8M) demonstrations and personal and collective well-being and to explore the psychosocial mechanisms involved in this relationship. 8M, now known as International Women’s Day, is a date to commemorate the long history of struggle and sacrifice to obtain women’s rights. While there is debate between multiple versions claiming historic origins, the most popular one is associated with working-class women’s demonstrations, the Suffragist Movement , and/or Despite many years of fighting for women’s rights, acknowledgment of equality among all human beings at the Human Rights Convention of 1945, the International Bill of Human Rights for Women of 1979, and multiple conventions . It draws noteworthy social and media visibility all around the world e.g., , as it sAdditionally, demonstrations are a public and collective display of a collective’s opposition to or dissatisfaction with policies and practices of institutions and governments; as such, it is a customary and relevant tactic in all social movements . PreviouIn this work, we study the relationship between participation in the 8M demonstrations, affective well-being, the connection with values and beliefs, social cohesion and integration, individual and collective empowerment, and the intention of prosocial behavior focused on the struggle for women’s rights. First, we propose that 8M demonstrations, with a long tradition of annual periodicity (fixed and pre-established date), stereotyped synchronic behavior or gestures , consolidated common symbols , and shared values, can be partially conceived of as collective rituals , consideConsequently, we propose that the 8M demonstrations in favor of women’s rights as collective rituals be characterized by increased social interaction, a shared meaning intended to create a feeling of community , and socWith this research, we shall examine different psychosocial mechanisms involved in this relationship, integrating different theoretical perspectives: rituals and collective effervescence e.g., , positivFinally, based on the theory of collective action and social change , we posiIn this regard, we postulate that participation in the 8M demonstration causes collective effervescence, which provides communion or fusion of all feelings in a shared affective experience, and sharing emotions intensifies said affective experience. PES is the result not only of the experience of shared emotions felt but also of the entire experience of collective synchronization of all different facets of the affective experience.PES is the joy of demonstrating and increased emotions of high excitement with clearly positive components (joy and euphoria) among those participating in a successful collective meeting, whether a demonstration, a ritual, or any other kind of meeting . HoweverMoreover, we can expect that collective effervescence will be related to the emotional experience of self-transcendence. It has been proven that a subset of positive emotions  are able to mobilize people to connect with others in their environment or society. These emotions are elevation or moral inspiration, compassion, gratitude, feeling moved by love, and wondrous awe when witnessing a grandiose social object . These aPrevious studies have shown that PES is associated with social identification, social integration, fusion identity, enhanced personal and collective empowerment, positive affect, and positive shared beliefs among participants . These rFirst, it has been shown that participation in collective emotional gatherings increases identification with other co-present participants and also reinforces a broader sense of social identity  and more agreement with the values promoted by the ritualized collective action.This hypothesis is consistent with a previous and continuous line of research about participation and the role of PES (collective effervescence measure) as a predictor or mediator of the positive causal effects of participation in rituals and collective gatherings  involved in participation in demonstrations on 8 March 2020, collective and ritualized feminist actions, and their psychosocial correlates. These correlates are affective well-being, connection with values and beliefs, social well-being based on cohesion and social integration , empowerment , and the intention of prosocial behavior aimed toward the fight for the rights of women in different countries.To this end, we studied participation in 8M demonstrations. First, we verified the differences between the demonstrators and the non-demonstrators (audience or mass-media followers), as well as differences based on gender, using mean comparison. Moreover, we calculated average effect sizes with random effects for the countries total. Finally, by using a sequential measurement model, we examined the mediator effect (indirect effects) of each one of the psychosocial mechanisms, including PES in relation to each criterion variable. The criterion variables were as follows: the experience of transcendence, the situated social identity, identity fusion , solidarity, collective efficacy, individual and collective positive growth, and, lastly, the intention to help fight for women’s rights. Indirect effects of age and political-position variables were controlled out of all variables in the model. The sequential mediation model set forth above  is shownAccordingly, the following hypotheses were raised: (H1) During the 8M, behavioral and attentional synchrony will occur, along with emotional synchrony (PES-collective effervescence); moreover, positive emotions will be activated with high intensity, including emotions of transcendence, both in demonstrators and in non-demonstrators and followers alike. (H2) The psychosocial mechanisms will be linked to the effects: the experience of self-transcendence, situated social identity, and identity fusion with collectives representing the ritual , solidarity with women, collective efficacy, individual and collective growth, and the intention of behavior linked to the movement for women’s rights . (H3) Th1, audience, or followers on 8M. In both groups, the female percentage who responded to the survey was a majority, even more so and especially among the group of demonstrators  and Europe . In all nine countries, the 8M demonstrations showed similar characteristics. Symbolic elements were shared, as well as the use of choreography and dance, and a common language in favor of women’s rights. A brief ethnographic description is presented in tors see .2 2020 in nine different countries, and the approximate time spent on the survey was 30 min. The sample collected was convenience sample.Contact was established with social psychology research groups in Latin America and in Europe for a cross-cultural sample. With the Qualtrics Survey Platform®, online surveys were prepared both in Spanish and in Portuguese, accessed via a link. After the demonstrations on 8M, the links were shared with those who participated directly in the 8M 2020 demonstrations (demonstrators) and people who had followed the demonstrations through mass media and social networks . The data were collected between 8 March and 30 MarchThe procedure for data collection in all countries was similar; convenience sampling was used in all locations, and QR codes from the Qualtrics application were shared through a snowball scheme see . The samAll study participants read and accepted informed consent. The data recorded were alphanumerically code to ensure anonymity following the Organic Law on the Protection of Personal Data (BOE-A-2018-16673) and compliance with the regulation of the Ethics Committee for Research Involving Human Beings (CEISH) by the University of the Basque Country.The scales used in this research are based on a proposal made by ad hoc items were developed to measure the shared attention and behavioral synchrony, antecedents of collective effervescence . A Likert scale was used, with a response range of 1  to 7 . The reliability coefficient was adequate (Cronbach’s α = 0.729).Based on We felt more intense emotions because we all went through the same experience). Response ranges go from 1  to 7 . Cronbach’s coefficient was high (α = 0.883).A reduced version of six items was used see  of the PIntense positive emotions: Research was conducted on the prototypical positive emotions from the N (2013) scale with three items referring to feeling realized, happy, and alive during the 8M demonstration. The response range went from 1 (Nothing) to 7 . Cronbach’s reliability coefficient was high (α = 0.932). Transcendent emotions: Participants were asked about the transcendent emotions they felt in relation to the 8M demonstration, using the adapted version of the DES scale . The response range went from 1 (Nothing) to 7 . Cronbach’s reliability coefficient was very high (α = 0.955).Two types of positive emotions were assessed. based on  with fivI felt like there was something transcendent, associated with values and ideals, above the action) the degree of transcendence experienced by the subjects in relation to the 8M demonstration  to 7 . The reliability coefficient was very satisfactory (α = 0.922).Four Likert-style items were used to research . Response ranges went from 1  to 7 . The reliability coefficient score was very high (α = 0.946).Participants were asked about their degree of identification with the demonstrators  by meansWhich picture best describes your relationship with …), one for each reference group, two situated within the context (participants in the specific demonstration and feminists), and another one as a general category, with women . The five response options range from A to E, where A symbolizes a lesser perception of closeness or fusion  and E is a greater closeness or fusion .To assess identity fusion, the pictorial scale of identity fusion was used . Based oI feel  committed to women], taken from Totally disagree) to 7 . The reliability coefficient was satisfactory (α = 0.908). This version of the scale has been applied in different research works, demonstrating reliability and structural validity with a common dimension . The response range goes from 1  to 7 , and the reliability coefficient (Cronbach’s α) was high (α = 0.919).Four items extracted from I have changed my priorities about what is important in life), with a high reliability coefficient (α = 0.933), and three items for positive collective growth . The response range goes from 0 (No change) to 5 (Very great), with a reliability coefficient that is also high (α = 0.917).In order to assess positive growth, we used six items of positive growth scale from Committing 2 h per week to collaborate with an association that organizes marches). The response range goes from 1 (Nothing) to 5 (A lot). The reliability coefficient was high (Cronbach’s α = 0.890).Seven Likert-style items were created to assess the participants’ behavior intention in future participation in actions, organizations, and initiatives for women’s rights  and their sociodemographic features: age, gender , educational level , and political position .Participants provided information regarding their participation in 8M  and correlations, and mean comparisons (GML) with SPSS® 26.0. To test indirect effects only on female participants, we used mediation analysis (Model 6), using the macro PROCESS 3.3 . We usedr, calculated by countries, as the measurement of the size of the effect. We conducted a random-effects meta-analyses model. We explored the average effect size (magnitude) of the relationship between PES and each criterion variable, and heterogeneity indexes. To evaluate the effect sizes, the following criteria were adopted: r < 0.18 was small, 0.18 < r < 0.32 was medium, and r > 0.32 was large. This approach was undertaken due to the problematic use of r are indicators of the validity of the magnitude of the effect or of the validity of the relation between the variables. Heterogeneity/homogeneity in effect sizes by country was calculated with the Q statistic. The following tests were also added: the Rosenthal test, fail-safe N, which reports the number of studies that must be added for the size of the average effect to be statistically insignificant, and Egger’s regression tests to detect possible publication or selection biases . Furthermore, all variables of interest were positively and significantly associated with each other. The size of correlation coefficients indicates the presence of moderate-to-strong positive associations between the variables analyzed. The rank of correlations fluctuates from the lowest correlation obtained for identity fusion with women and behavioral synchrony  to the highest one found between intense positive emotions and self-transcendence emotions , confirming H1 and H2. For correlations r > 0.70, we tested the collinearity index (see ndex see . All the2 = 0.219), pro-women behavior (η2 = 0.195), situated social identity (η2 = 0.181), and identity fusion with demonstrators (η2 = 0.195). The differences between female protesters and non-protesters (followers) are equally significant in all variables when the sample of female participants is analyzed. The female demonstrators display the highest score in all the variables studied (see As seen in died see . The sma2 = 0.072), pro-woman behavior (η2 = 0.072), situated social identity (η2 = 0.063), and experience of intense positive emotions (η2 = 0.062). When compared with male and non-binary gender respondents, female demonstrators were also found to display greater levels of identity fusion with women (η2 = 0.042). This was also the case for intense positive emotions (η2 = 0.032), self-transcendent emotions (η2 = 0.029), and PES (η2 = 0.025); overall, the effect size of gender differences was small. Differences between female and male participants were significant (p < 0.001) regarding such variables, except collective efficacy and positive individual growth. Please see The gender differences for each key variable score for the total sample are listed in r = 0.45 and r = 0.77 in all countries included in this research. Descriptive statistics and correlations by country may be viewed in The analysis of correlations by country displayed, in general, positive relations between PES and the criterion variables. Psychosocial mechanisms are positively and significantly associated with PES, with correlations between r of PES with all key variables. The data obtained revealed that PES displayed moderate-to-high positive and significant relationships with all variables  and emotions (r = 0.65), behavioral synchrony (r = 0.65), and intense positive emotions (r = 0.61). Furthermore, less intense but strong relationships were found for PES with situated social identity (r = 0.59), positive collective growth (r = 0.47), identity fusion with demonstrators (r = 0.43), social identity dimension of solidarity toward women (r = 0.43), pro-woman behavior (r = 0.41), positive individual growth (r = 0.41), collective efficacy (r = 0.41), and identification or identity fusion with feminists (r = .40). The lowest of the effects was found in relation to identity fusion with women (r = 0.27). All pooled effect sizes were statistically significant3.PES showed the strongest associations with self-transcendent experience  = 4.23, p = 0.181; I2 = 0.00], and the other is regarding the relationship between identity fusion and/or proximity to women . It is important to note that the analysis yielded non-significant Egger’s regressions in all cases  suggests consistent effects of the associations as well as the absence of potential selection biases with the samples used.The analysis of heterogeneity reveals the existence of two sizes of homogeneous effect in the nine countries of analysis. The first and with less variability is in the relation between PES and group efficiency . In particular, as seen in b = 0.52), intense positive emotions (b = 0.80), and self-transcendent emotions (b = 0.07). Regarding the connection between the mediating and dependent variables, our results revealed that not all paths emerged as significant (see b = 0.06) and self-transcendent experience (b = 0.04). PES was associated with a greater self-transcendent experience (b = 0.22), situated social identity (b = 0.14) and identity fusion with demonstrators (b = 0.06), and feminists (b = 0.05). Similar results were found in the case of intense emotions. The experience of intense emotions was related to higher scores on the same variables (with coefficients ranging from 0.12 in self-transcendence experience to 0.31 in identification with feminists), as well as with increased pro-woman behavior (b = 0.48). Unlike the precedent mediators, self-transcendent emotion levels were significantly associated with all dependent variables (standardized coefficients ranged from 0.24 in identity fusion with feminists to 0.53 in self-transcendent experience and collective efficacy).We applied a model of multiple serial mediation  to b = 0.73 . Overall, participation in 8M protests was indirectly related to the self-transcendence experience, situated social identity, identity fusion with demonstrators, feminists and women, solidarity toward women, collective efficacy, and pro-woman behavior via its linkages with behavioral synchrony, PES, intense positive emotions, and self-transcendent emotions. After the effects of the mediator variables were controlled for, the direct effects of participation (vs. non-participation) on solidarity toward women and collective efficacy were not significant, thus indicating the existence of complete mediations. Partial meditations were found for the rest of dependent variables . Hypothesis 4 has only been partially confirmed.All total indirect effects emerged as significant because the 0 value was not included in any of the CIs generated. Therefore, our results confirmed that behavioral synchrony, PES, intense positive emotions, and self-transcendent emotions successively mediate the associations of participation (vs. non-participation) in 8M demonstrations with all dependent variables. Indirect effects ranged from Globally, this study is consistent with Durkheim’s theoretical proposal , later dThe results obtained reveal that participation in collective rituals and gatherings, with emotional sharing and convergence, reinforces most of the attributes of subjective and psychological well-being . CompareAll the explanatory variables, particularly attentional and behavioral synchrony, PES, and positive emotions , are related to personal and social well-being, social integration, and empowerment. In addition, the PES was significantly but heterogeneously associated with the vast majority of the criterion variables and predicted them, except identity fusion with women and collective efficacy, which revealed homogeneous effect sizes in all countries. A recent meta-analysis on collective effervescence  supports the fact that there is a stable and solid association of PES and results related to personal and social well-being, agreement with values, social integration, empowerment, and prosocial behavior. In line with In this regard, the analysis of sequential mediation conducted on the sample of women supports a model wherein participation facilitates attentional and behavioral synchrony, sparks collective effervescence or PES, boosts positive and transcendent emotions, facilitates agreement and contact with values and the sacred, and drives all the results. Specifically, these results indicate that participation in demonstrations reinforces positive, self-transcendental emotions above emotional synchrony. Participation in demonstrations through PES and intense positive emotions feeds into contact with values, situated and in-group social identity, and identity fusion. Lastly, participation through feelings of self-transcendence reinforces all the results. The results underscore the importance of experiences and emotions of self-transcendence because of the PES, which encourages the positive effects of collective meetings. Recent research provides empirical evidence in this same direction . HoweverWe acknowledge the main limitations of this study First, we worked with a convenience sample, which is a limitation regarding inferences about the general population. Moreover, data collection in natural contexts makes more difficult to obtain large samples, diverse samples (age and gender), balanced numbers between countries , and types of participants in each country (Colombia and Brazil have lower percentages of demonstrators). Given the nature of 8M, the female population is over-represented, while male demonstrators are very few. Second, due to the correlational nature of the study and the characteristics mentioned above, some of the results may reflect previous differences between demonstrators and non-demonstrators, not necessarily linked to participation in the demonstrations, even with the statistical control that we undertook . We suggest that future research should include pre–post measures or control groups to minimize this limitation. Third, the sample also appears to be biased in favor of those willing to participate in in 8M 2020 (demonstrations and non-demonstrations) and the study, as well as toward a representative profile, given that attention was focused on assessing the impact of participation. It would be useful to include other study groups  to assess these effects, beyond the subjective perception of participation, and to include the impact of 8M on the community in general. This aspect, in addition to a longitudinal design, would allow control for possible prior differences between the compared groups ; in this correlational study, the effects of sociodemographic variables and political orientation have been controlled for. Lastly, collective effervescence and its relationship with the mid- and long-term effects of participation would be one of the objectives to include in future research. According to previous literature, these effects are limited over time. Despite the limitations of this study, we believe that significant contributions derive from the current research study. First, we are not aware of previous studies that analyze quantitative relationships between psycho-emotional effects of participating in international social mobilizations, as the ritualized demonstrations of 8M. There is a scar of peer-reviewed quantitative studies on the 8M participation and its psycho-emotional correlates, or its relation to variables such as individual and collective well-being, social cohesion, or individual and collective growth, among others. Second, this work shows the relevance of psycho-emotional mechanisms in both participants and followers. This aspect has been largely neglected in the scientific literature , given tIn sum, this research provides valuable insight to understand the psychological and emotional mechanisms (and their relationships) generated during collective participation in ritualized collective actions such as 8M demonstrations. These findings could also shed light on the relevant role of the experience of collective effervescence that improves personal and social well-being, social cohesion and integration, and empowerment of all participants, with more intensity in the reference group . Finally, the shared cognitive and emotional experience in ritualized collective actions serves to renew commitment to the community, to improve well-being, and to strengthen both the individuals and the groups involved. These shared emotional experiences may prove to be useful tools to promote social change and the transformation of societies, with the ultimate goal of working toward equality and prosocial models through collective political participation.Further inquiries can be directed to the corresponding authors. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.All study participants read and accepted informed consent. The data recorded was alphanumerically code to ensure anonymity following the Organic Law on the Protection of Personal Data (BOE-A-2018-16673), and compliance with the regulation of the Ethics Committee for Research Involving Human Beings (CEISH) by the University of the Basque Country.LZ, PC-A, LM, JP, AW, NB, SC, SP, GN-C, IA-A, and BT-G planned and contributed to this cross-cultural study, performed the questionnaires, drafted the manuscript, performed the calculations, discussed the results, and commented and revised on the manuscript. All authors coordinated the sample collection in their residence areas/countries, and contributed to the discussion of the results.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Material and methods: Eighty participants (44 women and 36 men) with MS (n = 22), PD (n = 31) and history of stroke (n = 27) were enrolled. All participants completed a questionnaire consisting of metrics, the Katz Index of Independence in Activities of Daily Living and the Hospital Anxiety and Depression Scale (HADS). Results: Fifty-five per cent of all participants did not present with anxiety or depression, 20% scored above the diagnostic threshold on the anxiety scale and 26% scored above the diagnostic threshold on the depression scale. Subgroup analysis revealed that anxiety and depression sufferers were 13.64% and 13.64% of MS patients, respectively; 22.58% and 35.48% of PD patients, respectively; and 22.22% and 25.93% of stroke survivors, respectively. There was a significant correlation between depression and independence level in the entire group and between depression and marital status in stroke survivors. Conclusions: Although depression and anxiety are highly prevalent in patients with neurological conditions, the disorder has a very individual nature and is not associated with the patient’s age, duration of a condition or concomitant diseases. Screening for depression and anxiety as a part of comprehensive approach may increase treatment efficacy in neurological patientsThe main arguments in support of researching anxiety and depression in patients with chronic somatic diseases are the prevalence of affective disorders in the population, somatic conditions as risk factors of affective disorders and the search for effective preventative and therapeutic strategies. The aim of the study was to determine the association between the functional status, selected sociodemographic characteristics and prevalence as well as severity of anxiety and depression in patients with multiple sclerosis (MS), Parkinson’s disease (PD) and history of stroke (S).  Out of all neurological conditions, there are three which, owing to their prevalence and social impact, pose a significant population-wide challenge, namely, multiple sclerosis (MS), Parkinson’s disease (PD) and stroke (S) ,2,3. AltThe challenges of living with chronic disease become sources of persistent stress, which may predispose a patient to develop a mental health condition. This is particularly true for anxiety and depression ,6,7. HenAnxiety and depressive disorder constitute a serious problem in neurological patients ,17,18,19Therefore, in the context of insufficient insight into the problem nowadays ,19, the Eighty participants, 44 women (55%) and 36 men (45%), at the mean age of 65.73 years (SD ± 11.25), hospitalised at the Department of Neurology, Medical University of Silesia in Katowice were enrolled. The following inclusion criteria were used, a diagnosis of one of the three neurological conditions  willingness to participate, and sufficient cognitive ability assessed using Mini Mental State Examination  with a minimum score of 27 . Twenty-All participants completed a questionnaire consisting of metrics, the Katz Index of Independence in Activities of Daily Living (ADL) and the Hospital Anxiety and Depression Scale (HADS). The metrics section ascertained the participant’s sex, age and duration of neurological condition. as well as other comorbid chronic diseases, i.e. heart disease, hypertension, respiratory diseases, diabetes, gastric ulcer, kidney disease, liver disease, anaemia or other blood diseases, cancers, osteoarthritis, back pain and rheumatoid arthritis. All above comorbidities were totalled and included in a statistical analysis, excluding the primary neurological condition used as an inclusion criterion. Sociodemographic characteristics were ascertained using closed-ended questions and included education , marital status (single/ in a relationship), place of residence  and household type . Functional independence level was assessed using Katz Index of Independence in Activities of Daily Living (ADL). It is a patient–reported six–item scale assessing the level of independence in activities of daily living. Score of 5 or 6 indicates full independence, score of 3 or 4 indicates moderate functional impairment, whereas the score of 2 or below indicates severe functional impairment. The Katz Index of Independence  in ActivThe mental health assessment was based on the Polish version of the Hospital Anxiety and Depression Scale (HADS), which monitors depression and anxiety in patients with somatic conditions . It is aThe study procedure complied with the Declaration of Helsinki. Patient anonymity was ensured and willingness to participate was one of the inclusion criteria. According to Polish law, such observational studies are not medical experiments and, thus, do not require the approval of the Bioethical Committee of Medical University of Silesia in Katowice under resolution KNW/0022/KB/165/19 (Approved on 12 June 2019).p < 0.05 was assumed in all analyses. The study cohort was divided into three condition-based subsets of MS patients , PD patients  and stroke survivors (S) . The internal reliability of HADS was sufficient, with a Cronbach alpha of 0.76 (mean correlation between the items of r = 0.45) and 0.78 (r = 0.57) for depression and anxiety, respectively.Descriptive statistics  were calculated for each variable and expressed as numbers and percentages, respectively. The internal reliability of HADS was determined using Cronbach’s alpha. Non–parametric tests were used for comparisons. The correlation between the variables was determined using Spearman’s rank correlation coefficient. For continuous variables, chi-square, Mann‒Whitney U ANOVA and Kruskal‒Wallis ANOVA tests were used. The statistical significance of The cohort was relatively homogeneous. Participant comparison with sex as a grouping variable yielded no significant differences in age, duration of neurological condition, anxiety, depression and level of independence. Similarly, there were no significant sociodemographic differences between the study subsets with the exception of age differences .All patients had up to six comorbid somatic conditions. The mean number of chronic diseases per participant was 2.36 (SD ± 1.66). Age, number of comorbidities and duration of neurological condition did not significantly predict anxiety, depression and level of functional independence.There were no significant between–group differences in the level of functional independence, severity of anxiety and depression, as well as sociodemographic characteristics , which iThere was a significant effect of the level of independence on depression in the studied cohort. There was a significant effect of marital status on depression in the "S" subset . Anxiety and depression in patients with chronic conditions have been discussed by many authors. The Polish population study by Dróżdż et al. , conductThere is not enough empirical research to address anxiety and depression in neurological patients, and the available data is very discrepant. Our results demonstrated that affective disorder is highly prevalent in neurological patients, affecting between a fifth (anxiety) to over a quarter (depression) of all patients. In the current study, anxiety and depression was the most prevalent in patients with PD with the lowest prevalence in patients with MS. Richard et al.  estimateA more detailed analysis of our findings presents the problem of depression and anxiety in neurological patients as even more broad–scale. Including borderline scores as indicative of high–risk group, it affected almost half of study cohort , which aDepression and anxiety are more commonly seen in patients with neurological conditions than with other somatic conditions. Such affective disorders have a very individual nature and are not associated with patient’s age, duration of a condition or concomitant diseases. Depression and anxiety screening in neurological patients may become a significant contribution to the comprehensive approach to treatment, which increases its efficacy and improves the quality of life.


Background and objectives: Bipolar disorder (BD) is one of the most burdensome psychiatric illnesses, being associated with a negative long-term outcome and the highest suicide rate. Although affective temperaments can impact on BD long-term outcome, their role remains poorly investigated. The aims of the present study are to describe the clinical characteristics of patients with BD more frequently associated with the different affective temperaments and to assess the relation between affective temperaments and severity of clinical picture in a sample of patients with BD. Materials and Methods: A total of 199 patients have been recruited in the outpatients units of two university sites. Patients’ psychiatric symptoms, affective temperaments, and quality of life were investigated through validated assessment instruments. Results: Predominant cyclothymic and irritable temperaments are associated to higher number of relapses, poorer quality of life, higher rates of aggressive behaviors, and suicide attempts. Conversely, the predominant hyperthymic disposition was a protective factor for several outcome measures, including relapse rate, severity of anxiety, depressive and manic symptoms, suicidality, and earlier age at onset. One limitation of the present study is that the recruitment took place in two university sites; therefore, our findings cannot be fully generalized to the whole community of BD patients. Other limitations are the lack of a control group and the cross-sectional design of the study. Conclusions: The early identification of affective temperaments can help clinicians to identify those BD patients who are more likely to show a poor long-term outcome. An early screening of affective temperaments can be useful to develop targeted integrated pharmacological and psychosocial interventions. Bipolar disorder (BD) is a highly disruptive and chronic illness affecting between 0.3 and 1.5% of individuals worldwide ,3. Amongth Version (ICD-11) diagnostic manuals into discrete entities [BDs are currently categorized in well-defined diagnostic categories, which are operationalized by the Diagnostic and Statistical Manual for Mental Disorders – Fifth Edition DSM-5) and the International classification of Diseases – 11entities . However and the entities . In factentities .According to the concept of the bipolar spectrum, the assessment of affective temperaments and the clinical characterization of their association with psychiatric symptoms can contribute to explaining the heterogeneity of mood episodes, to identify predictive factors of good or poor outcome, and to select appropriate treatments .The term “temperaments” refers to the emotional domain of personality , and canThe different temperamental dispositions can be considered a subclinical (trait-related) manifestation of bipolar disorders that significantly contribute to their clinical course, including the direction of polarity, symptom profiles, and severity of affective episodes . The stuAccording to the available studies, cyclothymic temperament is often associated with young age at onset, high number of affective episodes, psychotic symptoms during acute phases ,19, and In this study, we aim to describe the clinical characteristics of BD more frequently associated with affective temperaments, and to explore which affective temperaments are associated with a more severe clinical picture and a worse long-term outcome of bipolar disorder. We hypothesized that several clinical indicators, including age at onset, number of affective episodes, and lifetime suicidal attempts are strongly correlated with the five affective temperaments proposed by Akiskal. In particular, we anticipate that the cyclothymic and irritable affective dispositions are associated with worse clinical picture and long-term outcome of the disorder.The study was carried out at the Mood Disorder outpatient Units of the Department of Psychiatry of the University of Campania “Luigi Vanvitelli” and of University Magna Graecia of Catanzaro. All referring patients between June 2019 and January 2020 were included in the study if they met the following inclusion criteria: (1) diagnosis of type-I or type-II bipolar disorder, confirmed by the Structured Clinical Interview for DSM-5 disorders; (2) age between 18 and 65 years; (3) willingness to participate in the study, expressed by written informed consent provided upon complete description of the protocol; (4) being in a stable phase of the disorder since at least 6 months. Exclusion criteria were: (1) inability to give a written consent to participate in the study; (2) diagnosis of any neurological disease; (3) presence of actual drug and/or alcohol abuse, according to the DSM-5. The study was carried out in accordance with the latest version of the Declaration of Helsinki and was approved by the Local Research Ethic Committee (Number: N001567/28.01.2018).Patients’ socio-demographic  and clinical characteristics  were recorded with an ad hoc schedule. Previous affective episodes have been defined according DSM-5 criteria. Alcohol misuse was defined as consuming eight or more drinks per week for women, or 15 or more drinks per week for men . Drug miDepressive and anxiety symptoms were assessed through the 17-item Hamilton Depression Rating Scale (HAM-D)  and the Descriptive statistics were calculated for socio-demographic and clinical characteristics, as well as for scores of relevant assessment instruments. Data were presented as means (M) and standard deviations (SD), or as frequencies and percentages (%), as appropriate. The Kolmogorov–Smirnov test was used to check the normality of distribution of our sample.t-Student test for independent samples was performed to assess the association of affective temperaments with clinical and socio-demographic characteristics expressed as discrete variables. According to the independent variables, linear and logistic regression models were performed to test whether affective temperaments can be considered predictors of outcome. These models were corrected for diagnoses, age, sex, and pharmacological treatments. The level of statistical significance was set at p < 0.05. Statistical Package for Social Sciences version 21 was used to perform the statistical analyses.We identified several socio-demographic and clinical characteristics that, on the basis of the existing literature, could be considered valid proxies for worse outcome, including age at onset, duration of untreated illness, total number of hospitalizations, total number of affective episodes, presence of aggressive behaviors, psychotic symptoms, and suicide attempts ,29,30. CA total of 199 patients have been recruited . Half oft-Student analyses are reported in p < 0.0001) and with the total number of affective episodes (p < 0.01), and negatively with the MANSA total score (p < 0.0001).Pearson’s correlations and p < 0.01), and negatively with the total number of hospitalizations (p < 0.001), the YMRS total score (p < 0.01), and with the HAM-D total score (p < 0.05).The hyperthymic temperament is positively correlated with age of onset (p < 0.01), and negatively with MANSA total score (p < 0.01).Anxious temperament positively correlated with the HAM-D total score (p < 0.01), and HAM-D total scores (p < 0.05), while it is negatively correlated with MANSA total score (p < 0.0001).Cyclothymic temperament showed a positive correlation with the total number of hospitalizations, HAM-A (p < 0.001), with YMRS total score (p < 0.01), and with the total number of hospitalizations (p < 0.05), and negatively correlated with the MANSA total score (p < 0.0001).Lastly, irritable temperament positively correlated with HAM-A and HAM-D total scores, with the total number of affective episodes (p < 0.0001)  .p < 0.01), or irritable (p < 0.001) temperaments. Psychotic symptoms are more frequently reported by patients with a predominant depressive or irritable (p < 0.0001) disposition. Substance misuse is reported only by patients with a hyperthymic temperament (p < 0.01), while suicide attempts are present in all temperamental dispositions, with the exception of the hyperthymic one, which seems to have an inverse association.Aggressive behaviors are more frequent in patients with cyclothymic, depressive (p < 0.05), having a worse quality of life (p < 0.05), more aggressive behaviors (p < 0.01), and more suicide attempts (p < 0.01). The predominant irritable temperament increases the risk of having more severe depressive symptoms (p < 0.05), a worse quality of life (p < 0.01), more aggressive behaviors (p < 0.01), more psychotic symptoms (p < 0.01), and more suicide attempts (p < 0.01). Patients with a predominant hyperthymic temperament have a later age at onset (p < 0.05), a reduced risk of being hospitalized (p < 0.01), less severe anxiety, depressive and manic symptoms (p < 0.05), and less frequent suicide attempts (p < 0.01), with an increased probability of substance abuse (p < 0.05). The anxious and the depressive temperaments are not associated with any of the considered outcome measures. According to the linear and logistic regression models , having The correlations between affective temperaments and long-term outcome of BD is an emerging theme. Most studies previously carried out on this topic have investigated the impact of single affective temperaments on single outcome measures, usually the number of relapses or hospitalization, the presence of drug abuse, suicide attempts, aggressive behaviors, and the severity of affective symptoms, but a comprehensive analysis on the relationship between the five affective temperaments and several outcome measures in BD is missing.The main finding of our study is that temperaments influence the clinical severity of bipolar disorder. In particular, patients with predominant cyclothymic and irritable temperaments have a higher number of relapses, a reduced quality of life, higher rates of aggressive behaviors, and suicide attempts. On the contrary, the hyperthymic disposition seems to be a protective factor against clinical severity, being associated with a lower relapse rate, less severe anxiety, depressive and manic symptoms, reduced suicidality, and earlier age at onset. Moreover, patients with an hyperthymic temperament presented drug misuse more frequently during affective episodes compared with the other four affective temperaments.These data are consistent with available literature and show that the hyperthymic temperament is orthogonally different from all the other affective dispositions . The hypAnother clinically relevant finding is that the hyperthymic temperament is associated with a better symptom profile and less suicide attempts . This fiNotably, our results show that the hyperthymic disposition increases the likelihood to present drug misuse in patients with BD. In a previous study, Singh et al.  found thAnother significant finding is the strong relationship of cyclothymic and irritable temperaments with the severity of clinical symptoms. In fact, those patients present more severe anxiety and depressive symptoms, a higher number of relapses and hospitalizations, more frequently psychotic symptoms, more aggressive behaviors, and suicide attempts. Most of these associations have been confirmed at the multivariate analyses, showing that patients with predominant cyclothymic or irritable dispositions have a highly recurrent course of illness, with a pattern of impulsiveness, suicidality, and reduced quality of life. This finding may be related to the high mood lability and emotional overactivity, as well as to impulsive–aggressive emotionally erratic behaviors and hypersensitivity that are characteristic of these two affective dispositions . MoreoveOur results also showed the presence of a considerable overlap between the cyclothymic and irritable temperaments in terms of psychopathological characteristics, thus confirming that these two dispositions operate simultaneously rather than being two different dimensions . Future Although several outcome measures correlate with depressive  and anxious  temperaments, none of these correlations is confirmed at the regression analyses. These findings confirm that the depressive and anxiety temperaments cannot be considered strong predictors of poor outcome of patients with bipolar disorder ,15,20,34The following limitations should be acknowledged. First, given the limited sample size and the fact that the recruitment took place in two university sites only, our findings cannot be fully generalized to the whole community of patients with bipolar disorder. Second, there is a lack of a control group made by patients affected by another mental disorder; therefore, we could not clarify if the impact of the affective dispositions on clinical severity and long-term outcome is disease-specific or can be applicable to other mental disorders. Another limitation is the fact that the correlation between affective temperaments and the presence of other psychiatric comorbidities was not considered. However, all comorbidities will be analyzed in further analyses from our dataset. Last, the cross-sectional design of the study did not allow us for multiple assessments. Although affective temperaments can be considered stable traits, multiple assessments can provide a more accurate and ecological assessment of outcome measures associated with affective dispositions.In conclusion, our results highlight that the different affective temperaments have a different predictive role on clinical severity and outcome of bipolar disorder. In particular, while the cyclothymic and irritable temperaments seem to be risk factor for a worse outcome, the hyperthymic temperament has a more protective role. Since affective temperaments are considered innate, enduring, and stable traits, an early assessment of temperaments could help to identify those BD patients who are more likely to present a more severe long-term course and outcome. An early screening of affective temperaments can be used to develop personalized and integrated early pharmacological and psychosocial interventions to patients with bipolar disorder, according to the precision medicine approach.


Being overweight and obese is a serious public health issues in China. However, the effects of substance use and mental factors on weight changes remain unclear. In this study, we aimed to investigate the association among self-perceived stress, history of smoking and drinking, and weight status by using data from the China Health and Nutrition Survey in 2015.A total of 8028 adults were selected from China Health and Nutrition Survey in 2015. The self-reported data primarily included sociodemographic data, self-perceived stress scores, and history of smoking and drinking. Physical measurements including height and weight were logged to calculate body mass index. Multivariate and multinomial regression models were used to estimate effects of substance and perceived stress on weight status.The prevalence of underweight and overweight/obese people were 4.52% and 51.51% in Chinese adults, respectively. Adults with high perceived stress were negatively associated with being overweight and obese . Adults with history of smoking had low risk of being overweight/obese . Adults with history of drinking had high risk of overweight/obese . In addition, the association between drinking and overweight/obese was affected by different levels of perceived stress .The effects of self-perceived stress and history of smoking as well as drinking on weight status were significant in this study. The government and healthcare policymakers should strengthen early psychological factor and behavioral intervention to decrease the prevalence of abnormal-weight status. Overweight/obesity is associated with many chronic diseases, such as hypertension, cardiovascular disease, diabetes, and cancer.–4With the widespread studies on nutrition, overweight and obesity are serious public health concerns. The National Health Commission of the People's Republic of China showed that the prevalence of overweight and obesity are 30.1% and 11.9% in adults and 9.6% and 6.4% in adolescents, respectively.Meanwhile, individual stressful status also attracted the attention of researchers. Self-perceived stress is the individual ability to deal with risk behavior and emotional problems, and vulnerable people are sensitive to stress threshold. By contrast, low perceived stress was beneficial for people's health because people with low stress was associated with positive social support, which can play the “buffering” role of negative emotions. Moreover, perceived stress is at an increased risk of substance dependence. A large cross-sectional survey from 41 countries showed that increased stress is associated with smoking in Africa, America, and Asia. However, the relationship of perceived stress with alcohol behavior is controversial and unclear. In a clinical trial, patients with high anxiety level are strongly associated with alcohol use disorder; this association is not present in perceived stress. Empirical research also suggested that high stress is associated with cigarette smoking, recent increase in smoking, and low self-efficacy to quit smoking in working adults, but work stress does not predict alcohol use. A meta-analysis from Europe indicated that nondrinkers and heavy drinkers are connected with job strain compared with moderate drinkers in cross-sectional and longitudinal studies. Hence, stress and substance can pose combined effects on individual health.Previous studies reported the association of stress with health status and behavior. For example, work stress is associated with hypertension, peptic ulcer, and cancer. A longitudinal study reported that body mass index (BMI) score were significantly higher in the moderate- and higher-stress groups than the lower-stress group during the all 5-year study.. One possible explanation for this phenomenon is that substance plays potential role between negative emotion and weight status, that is, negative emotion would increase the frequency of substance use to impose indirect effect on weight.The association between mental condition and weight status has been widely studied and discussed. Individual psychological factors can influence weight level through the change in substance use. A cross-sectional in China found that current depression accounts for higher risk than smoking in obese women, but this result is insignificant in underweight/normal and overweight groups. A empirical research showed that both the perceived stress and all alcohol consumption habits with respect to obesity had significant interactions. In summary, the effects of perceive stress on weight change should be studied by different levels.However, the role of stress is few between substance and obese in previous studies, and stress may have special mechanism in this relationship. For example, teenagers are more vulnerable than adults in terms of difficulty; workers have higher stress tolerance than nonworkers. The different stress levels would be extremely significant in various groups. Evaluating the degrees of stresses would help in understanding its moderating role in various group. A literature revealed that although this difference is unsupported between nonsmokers and smokers in terms of BMI and perceived stress, nonsmokers with high perceive stress level reported increased food intake, and smokers reported eating less than usual.The majority of studies primarily considers the association between the mental condition and substance use among adolescent. Few studies have examined the moderating effect of perceive stress between substance use and weight changes by using a large sample. To understand this mechanism in Chinese environment. We collected the data from China Health and Nutrition Survey (CHNS) in 2015 to investigate the main effect of self-perceived stress and the history of drinking/smoking on weight status in Chinese adults. Meanwhile, we also explored the moderating effect of self-perceived stress between the history of drinking/smoking and weight status among Chinese adults.22.1The CHNS has been approved by institutional review boards at the University of North Carolina at Chapel Hill and the National Institute for Nutrition and Food Safety, China Centre for Disease Control and Prevention. All participants provided written informed consent for their participation in the survey.2.2https://www.cpc.unc.edu/projects/china).The study data were derived from CHNS, which is an ongoing longitudinal survey project that was established and conducted by Chinese Center for Disease Control and Prevention and the University of North Carolina at Chapel Hill. These panel data were used to investigate the change in Chinese economic and social transformation with regard to its influence on the health and nutrition of Chinese people and assess the Chinese government's policies on how it affects medical resources allocated since 1989. Follow-up data were updated in 1991, 1993, 1997, 2000, 2004, 2006, 2011, and 2015. This study included most of Chinese provinces, including 12 provinces and 3 municipalities . The 2015 wave data was used in this study, and available website was supported to download questionnaires and data , cities and counties per province were stratified. Then, 2 urban and 2 suburban areas within cities, 1 community in down, and 3 villages within counties were randomly selected. A total of 13 890 adults and 5584 households were enrolled in the 2015 dataset. In present study, we primarily chose the individual survey of demographic data and health services data. In particular, CHNS first designed the scale of self-perceived stress to explore adults’ mental health in 2015. Enrolled participants who missed research and control variables were excluded. Finally, 8028 subjects who aged above 18 were included into current analysis in total.2.4The independent variable was the individual self-perceived stress scores, which was calculated using 14 items. The participants rated each item on a 5-point scale, which ranged from 1 (never) to 5 ; items 4 to 6, 9, 10, and 13 were reversely scored. High scores indicated high perceived stress possibility, as shown in Table 2.52). Second, the weight status was categorized into 4 types, namely, underweight (BMI < 18.5 kg/m2), normal weight (18.5 kg/m2 ≤ BMI < 24 kg/m2), overweight (24 kg/m2 ≤ BMI < 28 kg/m2), and obese (≥28 kg/m2).The dependent variables were BMI and weight status, which were derived through 2 steps. First, BMI was calculated as weight (kg)/height “have you drunk beer, liquor, or other alcoholic beverages in 2014?” (yes or no) and(2)“Do you smoke ?” (yes or no).2.7Control variables involved individual and household's sociodemographic variables, such as gender, age, residence, highest education levels, working status, marital status, living with parents, and tobacco consumption. Education was divided into junior high school and below, high school, and college and above. Marital status was divided into single, married, and separated/divorced/widowed. Residence was divided into urban and rural. Household income was split by percentage .2.8P < .05 (2-sided).The continuous data were described using mean ± SD, and the categories of data were proportions (%). Chi-squared and ANOVA tests were adopted to examine the difference between weight status and related variables. First, nested multivariate linear regression was used to assess the association among predictors and BMI value. Three models were used, as follows: model 1 adjusted for residence and gender; model 2 was further adjusted for perceived stress level; model 3 was further adjusted for other sociodemographic data and history of tobacco, as well as alcohol consumption, in 2014. We also utilized nested multinomial logistic regression to explore the effect of independent variables on unhealthy status . All the analyses were performed using STATA 15.1 . Statistical significance was considered when 33.1P < .001). The distribution of weight status showed certain differences between males and females (P < .001), that is, 59.23% accounted for underweight females, and 51.50% accounted for overweight/obese males. In 2015, 26.17% of adults reported that they had history of tobacco consumption in the underweight group, and 26.38% of the participants reported this rate in the overweight/obese group. A total of 20.04% of adults reported history of drinking in the underweight group in 2014, while this rate significantly increased to 30.46% in the overweight/obese group . The average self-perceived stress scores were 33.52 ± 6.69. In subgroup analysis, the difference was significant between the degree of stress and weight status (3.2P < .01). In model 2, after entering perceived stress, the association between BMI and perceived stress was negative (P < .01). In model 3, we conducted a full model with history of smoking and drinking. The results indicated that the effect of perceived stress was still significant after controlling the full covariates (P < .001). In addition, people with history of smoking are also an important predictor of BMI for adults in low BMI value, whereas history of drinking showed positive effects on BMI values. College education may play negative roles in the increase in BMI (P < .05). Lastly, marriage history and household income belonging to the middle level can also predict an increasing weight (P < .001), as shown in Table The multivariate regression model indicated that BMI values showed significant difference in gender and residence in model 1. Adults living in urban were more likely to be high weight, and the weight of males was 65% higher than that of females , but this association was not found between the underweight and normal groups. In model 3, we included other confounding factors, such as the history of alcohol and tobacco. The association between perceived stress and overweight/obese was still significant . Moreover, people with history of smoking had lower risks of being overweight or obese than nonsmoker . The adults with drinking were more likely to become overweight and obese than nondrinkers , and underweight and history of drinking was unassociated. Residence, gender, age, marital status, education, and household income were also associated with weight status, as shown in Table 3.4We conducted subgroup to analyses the change of substance’ effect on weight status. We did still not find the significant effect of substance on underweight models with different perceived stress. In addition, perceived stress cannot moderate the effect of smoking on overweight/obese in full stressful level . However, the moderation of perceived stress was examined between drinking and overweight/obese. In model 1 and model 2, the association between drinking and overweight/obese was insignificant. In model 3, drinker had great odds of overweight/obese . This result indicated that drinking was a important predictor of overweight/obese in high-level perceived stress, not for low-level perceived stress. , and females were a considerable majority in the underweight group compared with males . According to previous national monitoring data in 2010, the prevalence of overweight was 31.5% in men and 29.7% in women; the proportion of obese was 11.9% in men and 12.1% in women. The present study indicated that overweight and obesity of adult males had become a serious issue, which should draw the attention of the government and healthcare facilities.The strength of relationship among mental factor, substance use, and weight status is not always homogeneous because of the demographic difference in the country.–22 Moreover, a longitudinal study found that perceived stress is positively associated with leisure time and physical activity, as well as frequent fast food consumption. Another cross-sectional study pointed out that transit workers have high BMI and poor dietary habit when working in the highest work hours. However, our results were inconsistent with those of previous studies, and both associations were negative. This result can be explained in several manner. First, people with high stress would increase the perception of body image, thereby seeking slender shape, especially in younger adults. Second, the evidence from low- and middle-income countries should be supplemented. Developing countries were popular with vegetarian dietary model, that is, accounting for large dietary and cereals in daily diet compared with Western dietary pattern, and the decline in high fat food consumption can also influence the association between stressful diet and changes in weight. Third, the consumptions of tobacco and alcohol were typical among adults in China. Adults can experience individual stress by substance use increase of stressful diet.,27The present study found that perceived stress was negative associated with adult's weight status. Continues stress can regulate and affect fat storage, as well as change the microbial colonies in host, thereby leading to the vicious circle of overeating. Smoking can also inhibit pancreatic exocrine secretion, thereby influencing the amount of food and even triggering pancreatic cancer. Smoking can excite sympathetic nerves, thereby increasing energy consumption. Even former smoker had an average of 4–5 kg compared with current smoker. However, smoking is associated with massive chronic disease, such as the association with hypertension and diabetes, which bring harmful outcome more than benefit of weight decreased. In China, smoking is a popular factor in low- and middle-income areas; these people have high risks of being malnourished and to lack healthcare facilities.,32 Important environment and culture factors should be studied in the future. A total of 59.78% of underweight were from rural areas in CHNS 2015, which can provide a new sight into the relationship of tobacco use and overweight/obesity in urban–rural disparity.The risk of overweight or obese adults that were smoking was 29% lower than that of nonsmoker. This result indicated that smoking was negatively associated with BMI with the increase in emaciation rate and decrease in obese rate. The mechanism of smoking on weight management was unclear. One evidence suggested that carbon monoxide and nicotine in smoke can affect the digestive system through the jury of hypoxia on the nervous system with chronic gastritis and gastric ulcer. One reason for this result is the clustering of unhealthy lifestyle behavior, such as smoking, overnutrition, and physical inactivity, in this group.,35 These factors increase the risk of being overweight and obese. Although people with history of drinking are associated with physical activities, they also have increased frequency of unhealthy dietary behavior, such as eating barbecue and fast food.,37 These results indicated that the association between weight status and alcohol consumption had a complex connection.The history of alcohol consumption showed contrasting results. People with history of alcohol have prevailing sedentary behavior. pointed out that individual with high social status tends to have low stress levels and healthy weight status. Adults with high degree have received scientific knowledge and obtained high social position, while this group can intend to keep healthy and perform exercise compared with those with low education level. Moreover, middle income level was a significant predictor for overweight and obese. Similar to high education, rich men can develop healthy lifestyle behavior and keep their body weight in the normal level. Middle- and low-income levels have increased risks of poor nutrition because of fluctuating income and low education. Moreover, people with history of marriage are likely to be overweight and obese. Single adults have higher demands for body image to seek spouse. Hence, this group can keep their weight in the normal level. However, married adults should exert effort to work hard, which can influence one's weight. Marital strain and dissatisfaction can increase the risk of body weight gained because of the interfered self-regulatory behavior.Adults with college degree have low risk of being overweight/obese. Moore and CunninghamThe present study has several limitations. First, this study lacks panel data on individual's mental factors and body weight. Therefore, we cannot derive the causal effect in this cross-sectional study. Second, although we controlled several confounding variables into this model, the physical activity, sedentary behavior, and nutrition data are missing, and these materials can be extremely important in exploring the change in weight status. Third, the CHNS data showed nested structure among provinces, communities, and individuals. Therefore, the effect of cross-level should be considered in analysis, and mix effect model may lose large information, thereby decreasing test efficiency. Fourth, information of chronic disease is limitation in 2015 CHNS with mass missing and selected by self-reported versions. Hence, we cannot assess the influence of chronic disease on weight. This may weaken the validity of the study.5The prevalence of overweight and obese individuals was relatively high among Chinese adults in 2015. The study suggested that high perceived stress level may cover the risk of being overweight and obese among Chinese adults, but not for predicting underweight status. People with history of smoking had low risk to be overweight and obese. Alcohol consumption was likely to increase abnormal weight. Early psychological and behavior intervention should be implemented to prevent and improve Chinese adults’ weight status.The authors express their thanks to National Institute for Nutrition and Health, China Centre for Disease Control and Prevention and the University of North Carolina at Chaple Hill, NIH in CHNS project's contribution. We also grateful to Manoj Sharma of Jackson State University for assistance in manuscript language polishing and advices.Conceptualization, H.Y and MY.W; Methodology, W.L. and Y.Z; Validation, HD.Z; Formal Analysis, H.Y; Data Curation, MY.W; Writing-Original Draft Preparation, H.Y and MY.W; Writing-Review & Editing, HD.Z; Visualization, H.Y. and MY.W.