Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2017: 2.093
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Does cyberbullying occur simultaneously with other types of violence exposure?
Marlene A. Vieira; John A. Ronning; Jair de J. Mari; Isabel A. Bordin

OBJECTIVE: Our study aimed to verify whether cyberbullying victimization among adolescents occurs concomitantly with other forms of violence exposure (at home, at school and in the community).
METHODS: A collaborative longitudinal study by Norwegian and Brazilian researchers was conducted in Itaboraí, a low-income city in southeast Brazil. At baseline, trained interviewers applied a semi-structured questionnaire to a population-based sample of 669 in-school adolescents (11-15 years old). The investigated types of violence exposure included cyberbullying, traditional bullying, severe physical punishment by parents and community violence (victimization and eye-witnessed violent events outside the home and school).
RESULTS: In the previous six months, 1.9% of the adolescents had been victims of cyberbullying, and 21.9% had been victims of physical aggression, verbal harassment and/or social manipulation by peers. However, only 5.5% of the adolescents considered themselves bullying victims. In the previous 12 months, 12.4% of adolescents had suffered severe physical punishment, 14.0% had been victims of community violence, and 20.9% eye-witnessed community violence. Multivariable regression analysis showed that victimization by multiple types of traditional bullying and self-perceived bullying victimization were correlates of cyberbullying victimization, while suffering violence at home and in the community were not.
CONCLUSION: This study provides evidence of an association between cyberbullying, traditional bullying and self-perceived bullying among low-income Brazilian adolescents.

Descriptors: Adolescence; cyberbullying; bullying; child abuse; community violence

Cost-effectiveness analysis of the treatment of mild and moderate Alzheimer's disease in Brazil
Luciana R. da Silva; Cid M.M. Vianna; Gabriela B.G. Mosegui; Antônio A.F. Peregrino; Valeska Marinho; Jerson Laks

OBJECTIVE: To perform a cost-effectiveness analysis of donepezil and rivastigmine therapy for mild and moderate Alzheimer's disease (AD) from the perspective of the Brazilian Unified Health System.
METHOD: A hypothetical cohort of 1,000 individuals of both sexes, aged >65 years, and diagnosed with AD was simulated using a Markov model. The time horizon was 10 years, with 1-year cycles. A deterministic and probabilistic sensitivity analysis was performed.
RESULTS: For mild AD, the study showed an increase in quality-adjusted life years (QALYs) of 0.61 QALY/21,907.38 Brazilian reais (BRL) for patients treated with donepezil and 0.58 qAlY/BRL 24,683.33 for patients treated with rivastigmine. In the moderate AD group, QALY increases of 0.05/BRL 27,414.96 were observed for patients treated with donepezil and 0.06/BRL 34,222.96 for patients treated with rivastigmine.
CONCLUSIONS: The findings of this study contradict the standard of care for mild and moderate AD in Brazil, which is based on rivastigmine. A pharmacological treatment option based on current Brazilian clinical practice guidelines for AD suggests that rivastigmine is less cost-effective (0.39 QALY/BRL 32,685.77) than donepezil. Probabilistic analysis indicates that donepezil is the most cost-effective treatment for mild and moderate AD.

Descriptors: Alzheimer's disease; economic issues; administration; geriatric psychiatry

Twelve-month utilization rates and adequacy of treatment for mental health and substance use disorders in Argentina
Alfredo H. Cia; Juan C. Stagnaro; Sergio Aguilar-Gaxiola; Sebastián Sustas; Edith Serfaty; Martin Nemirovsky; Ronald C. Kessler; Corina Benjet

OBJECTIVE: To estimate the 12-month prevalence of mental health services utilization (overall and by type of service sector), the adequacy of treatment provided, and sociodemographic correlates in the Argentinean Study of Mental Health Epidemiology (ASMHE).
METHODS: The ASMHE is a multistage probability household sample representative of adults in urban areas of Argentina. The World Health Organization World Mental Health Composite International Diagnostic Interview (WMH-CIDI) was used to evaluate psychiatric diagnosis and service utilization.
RESULTS: Among those with a disorder, 27.6% received any treatment in the prior 12 months. Of these, 78.3% received minimally adequate treatment using a broad definition and only 43.6% using a stringent definition. For individuals with a disorder, more services were provided by mental health professionals (17.7%) than by general medical professionals (11.5%) or non-healthcare sectors (2.6%). Younger individuals with low education and income were less likely to receive treatment; those never married and those with an anxiety or mood disorder were more likely to receive treatment. Among those in treatment, treatment was least adequate among younger individuals with low education and low income.
CONCLUSIONS: Policies to increase access to services for mental health disorders in Argentina are needed, as is training for primary care practitioners in the early detection and treatment of psychiatric disorders.

Descriptors: Epidemiology; mental disorders; health services; Argentina

Acute effects of ayahuasca in a juvenile non-human primate model of depression
Flávia S. da Silva; Erick A.S. Silva; Geovan M. de Sousa Jr.; João P. Maia-de-Oliveira; Vanessa de Paula Soares-Rachetti; Draulio B. de Araujo; Maria B.C. Sousa; Bruno Lobao-Soares; Jaime Hallak; Nicole L. Galvão-Coelho

OBJECTIVE: The incidence rate of major depression in adolescents reaches approximately 14%. This disorder is usually recurrent, without remission of symptoms even after pharmacological treatment, and persists throughout adult life. Since the effects of antidepressants take approximately 2 weeks to begin, new pharmacological therapies are under continuous exploration. Recent evidence suggests that psychedelics could produce rapid antidepressant effects. In this study, we evaluated the potential antidepressant effects of ayahuasca in a juvenile non-human primate model of depression.
METHODS: While living with their families, juvenile marmosets (8 males; 7 females) were observed on alternate days for four weeks during a baseline phase. This was followed by 8 weeks of an induced depressive state protocol, the social isolated context (IC), in which the animals were monitored in the first and last weeks. Subsequently, five males and four females were randomly selected for treatment, first with a single administration of saline vehicle (1.67 mL/300 g of body weight, via gavage), followed by a single dose of ayahuasca (1.67 mL/300 g of body weight, via gavage). Both phases lasted 1 week and the animals were monitored daily. A third week of sampling was called the tardive-pharmacological effects phase. In all phases the marmosets were assessed for behavior, fecal cortisol levels, and body weight.
RESULTS: After IC, the animals presented typical hypocortisolemia, but cortisol recovered to baseline levels 24 h after an acute dose of ayahuasca; this recovery was not observed in vehicle-treated animals. Additionally, in males, ayahuasca, but not the vehicle, reduced scratching, a stereotypic behavior, and increased feeding. Ayahuasca treatment also improved body weight to baseline levels in both sexes. The ayahuasca-induced behavioral response had long-term effects (14 days). Thus, in this translational juvenile animal model of depression, ayahuasca presented beneficial effects.
CONCLUSIONS: These results can contribute to the validation of ayahuasca as an antidepressant drug and encourage new studies on psychedelic drugs as a tool for treating mood disorders, including for adolescents with early-onset depression.

Descriptors: Translational animal model; non-human primate; common marmoset; marmoset; cortisol; early-age depression; psychedelic drugs

How psychiatrists think about religious and spiritual beliefs in clinical practice: findings from a university hospital in São Paulo, Brazil
Maria C. Menegatti-Chequini; Everton de O. Maraldi; Mario F.P. Peres; Frederico C. Leão; Homero Vallada

OBJECTIVE: To examine the relationship between psychiatrists' religious/spiritual beliefs and their attitudes regarding religion and spirituality in clinical practice.
METHODS: A cross-sectional survey of religion/spirituality (R/S) in clinical practice was conducted with 121 psychiatrists from the largest academic hospital complex in Brazil.
RESULTS: When asked about their R/S beliefs, participants were more likely to consider themselves as spiritual rather than religious. A total of 64.2% considered their religious beliefs to influence their clinical practice and 50% reported that they frequently enquired about their patients' R/S. The most common barriers to approaching patients' religiosity were: lack of time (27.4%), fear of exceeding the role of the doctor (25%), and lack of training (19.1%). Those who were less religious or spiritual were also less likely to find difficulties in addressing a patient's R/S.
CONCLUSION: Differences in psychiatrists' religious and spiritual beliefs are associated with different attitudes concerning their approach to R/S. The results suggest that medical practice may lead to a religious conflict among devout psychiatrists, making them question their faith. Training might be of importance for handling R/S in clinical practice and for raising awareness about potential evaluative biases in the assessment of patients' religiosity.

Descriptors: Religion; ethics; education, psychiatric; psychotherapy

Studying ICD-11 Primary Health Care bodily stress syndrome in Brazil: do many functional disorders represent just one syndrome?
Sandra Fortes; Carolina Ziebold; Geoffrey M. Reed; Rebeca Robles-Garcia; Monica R. Campos; Emilene Reisdorfer; Ricardo Prado; David Goldberg; Linda Gask; Jair J. Mari

OBJECTIVE: Disorders characterized by "distressing unexplained somatic symptoms'' are challenging. In the ICD-11 Primary Health Care (PHC) Guidelines for Diagnosis and Management of Mental Disorders (ICD-11 PHC), a new category, bodily stress syndrome (BSS), was included to diagnose patients presenting unexplained somatic symptoms. The present study investigated the association of BSS with anxiety, depression, and four subgroups of physical symptoms in a Brazilian primary health care (PHC) sample.
METHODOLOGY: As part of the international ICD-11 PHC study, 338 patients were evaluated by their primary care physicians, followed by testing with Clinical Interview Schedule (CIS-R) and World Health Organization Disability Assessment Schedule, Version 2.0 (WHODAS 2.0). BSS was diagnosed in the presence of at least three somatic symptoms associated with incapacity. The association between anxiety, depression, and four subgroups of physical symptoms with being a BSS case was analyzed.
RESULTS: The number of somatic symptoms was high in the overall sample of 338 patients (mean = 8.4), but even higher in the 131 BSS patients (10.2; p < 0.001). Most BSS patients (57.3%) had at least three symptoms from two, three, or four subgroups, and these were associated with anxiety and depression in 80.9% of these patients. The symptom subgroup most strongly associated with ''being a BSS'' case was the non-specific group (OR = 6.51; 95%CI 1.65-24.34), followed by musculoskeletal (OR = 2,31; 95%CI 1.19-4.72).
CONCLUSION: Somatic symptoms were frequent in a sample of PHC patients in Brazil. In the present sample, one third were BSS cases and met the criteria for at least two symptom subgroups, supporting the hypothesis that different functional symptoms are related to each other.

Descriptors: Community mental health; stress; diagnosis and classification; somatoform disorders; bodily distress syndrome

Anxiolytic properties of compounds that counteract oxidative stress, neuroinflammation, and glutamatergic dysfunction: a review
Patrícia Santos; Ana P. Herrmann; Elaine Elisabetsky; Angelo Piato

OBJECTIVE: Anxiety disorders are highly prevalent and the efficacy of the available anxiolytic drugs is less than desired. Adverse effects also compromise patient quality of life and adherence to treatment. Accumulating evidence shows that the pathophysiology of anxiety and related disorders is multifactorial, involving oxidative stress, neuroinflammation, and glutamatergic dysfunction. The aim of this review was to evaluate data from animal studies and clinical trials showing the anxiolytic effects of agents whose mechanisms of action target these multiple domains.
METHODS: The PubMed database was searched for multitarget agents that had been evaluated in animal models of anxiety, as well as randomized double-blind placebo-controlled clinical trials of anxiety and/or anxiety related disorders.
RESULTS: The main multitarget agents that have shown consistent anxiolytic effects in various animal models of anxiety, as well in clinical trials, are agomelatine, N-acetylcysteine (NAC), and omega-3 fatty acids. Data from clinical trials are preliminary at best, but reveal good safety profiles and tolerance to adverse effects.
CONCLUSION: Agomelatine, NAC and omega-3 fatty acids show beneficial effects in clinical conditions where mainstream treatments are ineffective. These three multitarget agents are considered promising candidates for innovative, effective, and better-tolerated anxiolytics.

Descriptors: Anxiety; agomelatine; N-acetylcysteine; omega-3 fatty acids

Psychometric properties of the Liebowitz Social Anxiety Scale in a large cross-cultural Spanish and Portuguese speaking sample
Vicente E. Caballo; Isabel C. Salazar; Victor Arias; Stefan G. Hofmann; Joshua Curtiss; CISO-A Research Team

OBJECTIVE: To examine the psychometric properties of the Liebowitz Social Anxiety Scale-Self Report (LSAS-SR) based on a large sample recruited from 16 Latin American countries, Spain, and Portugal.
METHODS: Two groups of participants were included: a non-clinical sample involving 31,243 community subjects and a clinical sample comprising 529 patients with a diagnosis of social anxiety disorder (SAD). Exploratory factor analysis (EFA), confirmatory factor analysis (CFA) and exploratory structural equation modeling (ESEM) were used in order to determine the psychometric properties of the LSAS-SR.
RESULTS: EFA identified five factors with eigenvalues greater than 1.00 explaining 50.78% of the cumulative variance. CFA and ESEM supported this 5-factor structure of the LSAS-SR. The factors included: 1) speaking in public; 2) eating/drinking in front of other people; 3) assertive behaviors; 4) working/writing while being observed; and 5) interactions with strangers. Other psychometric properties such as interfactor correlations, invariance, reliability, and validity of the scale were also found.
CONCLUSION: Psychometric data support the internal consistency and convergent validity of the LSAS-SR. It seems to be a valid and reliable measure of global social anxiety for Spanish and Portuguese-speaking countries, although when considering a multidimensional approach (factor-based assessment) it seems to be lacking some relevant social situations that are feared in those countries.

Descriptors: Social anxiety disorder; questionnaires; psychometrics; cross-cultural comparison

Revictimization as a high-risk factor for development of posttraumatic stress disorder: a systematic review of the literature
Giuliana C. Cividanes; Andrea F. Mello; Marcelo F. Mello

OBJECTIVE: Much research has been published on the role of sexual revictimization in the emergence of mental disorders in adulthood, but findings have sometimes been contradictory. The present systematic review sought to assess the state of the evidence on revictimization as a potential factor for the emergence of posttraumatic stress disorder (PTSD).
METHODS: Electronic searches were conducted in five databases (MEDLINE/PubMed, Cochrane Library, Campbell Library, PsycINFO, and LILACS), using the terms PTSD, posttraumatic stress disorder, child abuse, and rape.
RESULTS: We identified nine articles that established a connection among childhood sexual abuse (CSA), sexual revictimization in adulthood, and development of PTSD. Eight of the nine papers included were classified as having strong methodological quality (grade VI). One was classified as IV, with an average quality-of-evidence rating. The mean methodological quality score of the articles was 5.5, and the quality of evidence was deemed strong.
CONCLUSION: In the included studies, PTSD symptoms were most prevalent in the CSA + adult sexual assault groups, providing further evidence for the revictimization hypothesis.

Descriptors: Child psychiatry; sexual assault; post-traumatic stress disorder; adult development; violence/aggression

Eating disorder symptoms in Brazilian university students: a systematic review and meta-analysis
Amanda P. Trindade; Jose C. Appolinario; Paulo Mattos; Janet Treasure; Bruno P. Nazar

OBJECTIVE: To synthesize the risk of eating disorder (ED) symptoms in Brazilian university students through a systematic review and meta-analysis. Secondary goals were to analyze whether any specific majors were related to higher ED risk and whether any regions of Brazil had higher proportions of college students at risk of ED.
METHODS: The procedures followed the Preferred Reporting Items for Systematic Reviews and Metaanalysis (PRISMA) guidelines, and a search was conducted in three electronic databases (MEDLINE, LILACS, and SciELO).
RESULTS: Thirty-three studies were included in the analysis, of which 14 were included in the metaanalysis. All included studies used self-report questionnaires, the most frequent of which was the Eating Attitudes Test (EAT-26). None of the studies used a structured interview to diagnose ED. A meta-analysis of studies with a cutoff ≥ 20 for the EAT-26 (n=5) found 14.9% (95%CI 12.8-17.2%) positive screenings, while those with a cutoff of t ≥ 21 (n=9) found 13.3% (95%CI 11.3-15.6%) positive screenings. There was a significantly higher proportion of positive screenings among nutrition majors than all other majors combined (26.5 and 20.5%, respectively).
CONCLUSION: Nutrition students seem to be at higher risk of ED. Further research should investigate whether positive screenings translate to actual ED diagnoses.

Descriptors: Eating disorders; epidemiology; nutrition; women; statistics

Cannabidiol presents an inverted U-shaped dose-response curve in a simulated public speaking test
Ila M. Linares; Antonio W. Zuardi; Luis C. Pereira; Regina H. Queiroz; Raphael Mechoulam; Francisco S. Guimarães; Jose A. Crippa

OBJECTIVE: Cannabidiol (CBD), one of the non-psychotomimetic compounds of Cannabis sativa, causes anxiolytic-like effects in animals, with typical bell-shaped dose-response curves. No study, however, has investigated whether increasing doses of this drug would also cause similar curves in humans. The objective of this study was to compare the acute effects of different doses of CBD and placebo in healthy volunteers performing a simulated public speaking test (SPST), a well-tested anxiety-inducing method.
METHOD: A total of 57 healthy male subjects were allocated to receive oral CBD at doses of 150 mg (n=15), 300 mg (n=15), 600 mg (n=12) or placebo (n=15) in a double-blind procedure. During the SPST, subjective ratings on the Visual Analogue Mood Scale (VAMS) and physiological measures (systolic and diastolic blood pressure, heart rate) were obtained at six different time points.
RESULTS: Compared to placebo, pretreatment with 300 mg of CBD significantly reduced anxiety during the speech. No significant differences in VAMS scores were observed between groups receiving CBD 150 mg, 600 mg and placebo.
CONCLUSION: Our findings confirm the anxiolytic-like properties of CBD and are consonant with results of animal studies describing bell-shaped dose-response curves. Optimal therapeutic doses of CBD should be rigorously determined so that research findings can be adequately translated into clinical practice.

Descriptors: Anxiety; cannabis; cannabidiol; CBD; simulated public speaking

Noninvasive brain stimulation in psychiatric disorders: a primer
Andre R. Brunoni; Bernardo Sampaio-Junior; Adriano H. Moffa; Luana V. Aparicio; Pedro Gordon; Izio Klein; Rosa M. Rios; Lais B. Razza; Colleen Loo; Frank Padberg, Leandro Valiengo

OBJECTIVE: Noninvasive brain stimulation (NIBS) techniques, such as transcranial direct current stimulation (tDCS) and repetitive transcranial magnetic stimulation (rTMS), are increasingly being used to treat mental disorders, particularly major depression. The aim of this comprehensive review is to summarize the main advances, limitations, and perspectives of the field.
METHODS: We searched PubMed and other databases from inception to July 2017 for articles, particularly systematic reviews and meta-analyses, evaluating the use of NIBS in psychiatric disorders.
RESULTS: We reviewed the mechanisms of action, safety, tolerability, efficacy, and relevant clinical parameters of NIBS. Repetitive TMS is already an established technique for the treatment of depression, and there is theoretically room for further methodological development towards a high-end therapeutic intervention. In contrast, tDCS is a technically easier method and therefore potentially suitable for wider clinical use. However the evidence of its antidepressant efficacy is less sound, and a recent study found tDCS to be inferior to antidepressant pharmacotherapy. Clinical trials using rTMS for other mental disorders produced mixed findings, whereas tDCS use has not been sufficiently appraised.
CONCLUSION: The most promising results of NIBS have been obtained for depression. These techniques excel in safety and tolerability, although their efficacy still warrants improvement.

Descriptors: Transcranial magnetic stimulation; transcranial direct current stimulation; mental disorders; major depressive disorder; review

Exploring the structural and construct validity of the Brazilian Food Cravings Questionnaire-Trait-reduced (FCQ-T-r)
Anna C. Queiroz de Medeiros; Lucia de F.C. Pedrosa; Maria E. Yamamoto

OBJECTIVE: Food cravings play an important role in the neurobiology of appetitive behavior, being positively associated with negative feelings, eating disorders, and obesity. This study aimed to assess the psychometric properties of the Brazilian Food Cravings Questionnaire-Trait-reduced (FCQ-T-r), a short version of the most widely used measure of this behavior.
METHODS: Undergraduate students (n=505) completed the full version of the FCQ-T and the Three-Factor Eating Questionnaire. Respondents' height and weight were also measured. Exploratory factor analyses were performed.
RESULTS: The FCQ-T-r exhibited a single-factor structure and satisfactory internal consistency (α > 0.80). A positive correlation was observed between FCQ-T-r scores and those of the original version. Furthermore, FCQ-T-r scores correlated positively with uncontrolled eating and emotional eating behaviors. No correlation was found between body mass index and FCQ-T-r scores. Considering our sample characteristics, we suggested specific FCQ-T-r cutoff points for males and females in the Brazilian population.
CONCLUSION: Our results support the structure of the Brazilian adaptation of the FCQ-T-r, which seems to be a viable instrument to investigate food cravings, particularly in time-constrained settings. Further studies are needed to verify these findings in other age ranges and clinical samples.

Descriptors: Eating behavior; psychometric; food craving

Component mechanisms of executive function in schizophrenia and their contribution to functional outcomes
Arthur A. Berberian; Ary Gadelha; Natália M. Dias; Tatiana P. Mecca; William E. Comfort; Rodrigo A. Bressan; Acioly T. Lacerda

OBJECTIVE: In schizophrenia, scores reflecting deficits in different cognitive processes are strongly correlated, making it difficult to establish a solid relationship between different cognitive mechanisms and other features of this disorder. The objective of this study was to explore whether three frequently postulated executive functions (updating, shifting, and inhibition) could be compared between groups and considered independently in terms of their respective roles in functional outcome.
METHODS: This study relied on confirmatory factor analysis of schizophrenia patients (n=141) and healthy controls (n=119). The main analyses examined the degree to which three executive functions (updating, set-shifting, and inhibition) could be separated in schizophrenia and compared this model among groups. Structural equation modeling analysis was also performed to examine the extent to which executive function components contribute to functional outcome in schizophrenia.
RESULTS: Multiple-group confirmatory factor analysis with unconstrained model parameters indicated that the full three-factor model may fit the data in both groups (χ2 = 61.48, degrees of freedom = 34, p < 0.001, comparative fit index = 0.95; standardized root mean square residual = 0.037; root mean square error of approximation = 0.04; Akaike's information criteria = 169.49; normed fit index = 0.90), although there was also a good data fit for the patient group with a two-factor model. In the patient group, structural equation modeling suggested that shifting and (principally) updating were associated with the general measure of functional outcome (regression path coefficients: 0.34, p < 0.005; 0.39, p < 0.005, respectively), although when combined the mechanisms fail to contribute.
CONCLUSION: This data suggests that the factor structure may be similar but not identical between groups, and both updating and shifting may play an important role in functional outcome in schizophrenia.

Descriptors: Schizophrenia; executive functions; functional outcome

Alcohol misuse among women in Brazil: recent trends and associations with unprotected sex, early pregnancy, and abortion
Luciana T.S. Massaro; Renata R. Abdalla; Ronaldo Laranjeira; Raul Caetano; llana Pinsky; Clarice S. Madruga

OBJECTIVE: This study compared the rates of binge drinking (BD) and alcohol use disorder (AUD) reported for 2006 with those reported for 2012, exploring their associations with unprotected sex, early pregnancy, and abortion in a representative sample of women in Brazilian households.
METHODS: This was a descriptive analysis of data from a cross-sectional study involving randomized multistage cluster sampling of the population ≥ 14 years of age. Weighted prevalence rates and odds ratios were estimated, and serial mediation analysis was performed.
RESULTS: A total of 4,256 women were analyzed. The BD prevalence was 35.1% and 47.1% in 2006 and 2012, respectively, a significant increase, especially among women 40-59 years of age. There was no significant difference in AUD prevalence. BD (without AUD) was found to increase the odds of unprotected sex and abortion. The path analysis showed that early pregnancy was a mediator of the relationship between alcohol consumption and abortion.
CONCLUSION: Among women in Brazil, the harmful use of alcohol is increasing, which has an impact on female reproductive health and exposure to risks. There is a need for specific prevention initiatives focusing on alcohol-related behaviors in women.

Descriptors: Brazil; alcohol abuse; binge drinking; female; abortion

PTSD in mental health outpatient settings: highly prevalent and under-recognized
Herika C. da Silva; Maísa M. Furtado da Rosa; William Berger; Mariana P. Luz; Mauro Mendlowicz; Evandro S.F. Coutinho; Carla M. Portella; Pamela I.S. Marques; Daniel C. Mograbi; Ivan Figueira; Paula Ventura

OBJECTIVES: To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training.
METHODS: We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records.
RESULTS: Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals.
CONCLUSIONS: These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

Descriptors: Prevalence; PTSD; underdiagnosis; outpatient psychiatry

Telomere length and childhood trauma in Colombians with depressive symptoms
Karen M. Jiménez; Angela J. Pereira-Morales; Ana Adan; Diego A. Forero

OBJECTIVE: Childhood trauma and telomere length (TL) are important risk factors for major depressive disorder. We examined whether there was an association between childhood trauma and TL in a sample of Colombians who were assessed for depressive symptoms.
METHODS: We applied the Center for Epidemiologic Studies Depression scale, the Patient Health Questionnaire-9, the Hospital Anxiety and Depression scale and the Childhood Trauma Questionnaire to 92 Colombian subjects (mean age = 21). TL was measured with quantitative PCR. Spearman's correlation coefficient (rs) was used to analyze the relationship between childhood trauma scores and TL.
RESULTS: We found a significant correlation between tL and sexual abuse scores (rs = 0.428, p = 0.002) in individuals with higher depressive symptom scores.
CONCLUSION: This is the first report of a significant association between TL and sexual abuse in a Latin American sample and provides additional evidence about the role of childhood trauma and TL in neuropsychiatric disorders.

Descriptors: Childhood trauma; depression; Latin America; sexual abuse; telomere length

Suicide risk configuration system in a clustered clinical sample: a generalized linear model obtained through the LASSO technique
María de la Paz Maino; Susana Morales; Orietta Echávarri; Jorge Barros; Arnol García; Claudia Moya; Tita Szmulewicz; Ronit Fischman; Catalina NUnez; Alemka Tomicic

OBJECTIVE: To identify clinical and sociodemographic factors that increase or decrease suicidal risk in a clinical sample of subjects seeking mental health care.
METHOD: A cross-sectional study was performed at three health centers in Santiago, Chile. The Parental Bonding Instrument (PBI), Depressive Experience Questionnaire (DEQ), Outcome Questionnaire (OQ-45.2), Reasons for Living Inventory (RFL), and State Trait Anger Expression Inventory (STAXI-2), in addition to a sociodemographic survey, were applied to 544 participants (333 with suicidal behavior and 211 without current suicidal behavior). Through hierarchical clustering analysis, participants were grouped by similarity regarding suicidal risk. Then, a regression analysis was performed using the Least Absolute Shrinkage and Selection Operator (LASSO) technique, and factors that decrease or increase suicide risk (SR) were identified for each cluster.
RESULTS: The resultant clusters were grouped mainly by the age of participants. The most important protective factor was having confidence in one's own coping skills in difficult situations. Relevant risk factors were major depressive disorder (MDD), poor anger management, and difficulties in interpersonal relationships.
CONCLUSIONS: Suicidal risk manifests differently throughout the life cycle, and different types of bonds may protect from or increase risk of suicide.

Descriptors: Suicide; mood disorders; adolescents; adult development; community mental health

Effects of resistance exercise training and stretching on chronic insomnia
Carolina V.R. D'Aurea; Dalva Poyares; Giselle S. Passos; Marcos G. Santana; Shawn D. Youngstedt; Altay A. Souza; Juliana Bicudo; Sergio Tufik; Marco T. de Mello

OBJECTIVE: The aim of this study was to assess the effects of resistance exercise and stretching on sleep, mood, and quality of life in chronic insomnia patients.
METHODS: Three 4-month treatments included: resistance exercise (n=10), stretching (n=10), and control (n=8). Sleep was evaluated with polysomnography, actigraphy, and questionnaires. Mood and quality of life were assessed with the Profile of Mood States (POMS) and the Medical Outcomes Study Short-Form 36-Item Health Survey (SF-36), respectively.
RESULTS: There were no significant treatment differences between resistance exercise and stretching. However, compared with the control treatment, resistance exercise and stretching led to significantly greater improvements in Insomnia Severity Index scores (-10.5±2.3, -8.1±2.0 vs. 2.3±1.8, respectively), and actigraphic measures of sleep latency (-7.1±4.6, -5.2±1.9 vs. 2.2±2.1 min), wake after sleep onset (-9.3±2.8, -7.1±3.0 vs. 3.6±4.2 min), and sleep efficiency (4.4±1.8, 5.0±0.8 vs. -2.3±2%). Pittsburgh Sleep Quality Index (PSQI) global scores (-5.3±0.8, -3.9±1.5 vs. -0.1 ±0.8) and sleep duration (1.2±0.3, 1.6±0.6 vs. -0.1±0.2 h) also improved following both experimental treatments compared with control. PSQI-Sleep efficiency increased after resistance exercise compared with control (19.5±3.9 vs. 2.1±4.3%). No significant differences were observed in polysomnography or quality of life measures. Tension-anxiety was lower in the stretching group than the control group.
CONCLUSION: Moderate-intensity resistance exercise and stretching led to similar improvements in objective and subjective sleep in patients with chronic insomnia.

Descriptors: Sleep; physical activity; mood; flexibility; strength exercise

The validity and reliability of the CAMDEX-DS for assessing dementia in adults with Down syndrome in Brazil
Luciana M. Fonseca; Glenda G. Haddad; Guilherme P. Mattar; Melaine C. de Oliveira; Sharon S. Simon; Laura M. Guilhoto; Geraldo F. Busatto; Shahid Zaman; Anthony J. Holland; Marcelo Q. Hoexter; Cassio M. Bottino

OBJECTIVE: Alzheimer's disease occurs at a higher prevalence and an earlier age in individuals with Down syndrome (DS) than typically developing individuals. However, diagnosing dementia in individuals with intellectual disability remains a challenge due to pre-existing cognitive deficits. The aim of this study was to investigate the validity and reliability of the Brazilian version of the Cambridge Examination for Mental Disorders of Older People with Down's syndrome and Others with Intellectual Disabilities (CAMDEX-DS) for individuals with DS.
METHODS: Two psychiatrists, working independently, evaluated 92 adults with DS ≥ 30 years of age. The concurrent validity of the CAMDEX-Ds was analyzed in relation to the gold standard of established international criteria. In a subgroup of 20 subjects, the concurrent validity of the CAMDEX-DS was analyzed in relation to an independent objective assessment of cognitive decline over three years. We analyzed the inter-rater reliability of cognitive assessment.
RESULTS: The diagnostic accuracy of the CAMDEX-DS compared to the gold standard was 96.7%. CAMDEX-DS-based diagnosis was considered consistent with cognitive decline. The probability of a participant with dementia having cognitive decline was 83%. Inter-rater reliability for the participant assessment was good, with a kappa of > 0.8 for 93% of the CAMDEX-DS items.
CONCLUSION: The CAMDEX-DS can be considered the first valid and reliable instrument for evaluating dementia in adults with DS in Brazil. Its use in such individuals could improve clinical practice and research.

Descriptors: Alzheimer disease; Down syndrome; diagnosis; dementia; intellectual disability

Prevalence of depression among patients with presumptive pulmonary tuberculosis in Rio de Janeiro, Brazil
Karina M. de Castro-Silva; Anna C. Carvalho; Maria T. Cavalcanti; Pedro da S. Martins; Jose R. Franca; Maria Oquendo; Afrânio L. Kritski; Annika Sweetland

OBJECTIVE: To estimate the prevalence of major depressive episode (MDE) in patients with presumptive pulmonary tuberculosis (pre-PTB, defined by cough lasting ≥ 3 weeks) and compare it between patients with pulmonary tuberculosis (PTB) and without PTB.
METHODS: Patients with pre-PTB (n=260) were screened for depression using the Patient Health Questionnaire (PHQ-9). Those individuals with scores ≥ 10 were subsequently assessed with the depression module of the Mini International Neuropsychiatric Interview (MINI-Plus) to confirm diagnosis. Associations of categorical variables with PTB and MDE were calculated using the chi-square test and OR.
RESULTS: PTB was confirmed in 98 patients (37.7%). A high proportion of both groups (active PTB and no PTB) screened positive for depression (60.2 vs. 62.1%, respectively). Among 159 patients who screened positive for depression, a subset of 97 (61.0%) were further evaluated with the MINI-Plus; current mDe was confirmed in 54.6% (53/97). On univariate and multivariate analysis, female sex was the only factor associated with the diagnosis of current MDE (p = 0.04).
CONCLUSION: The prevalence of MDE was high among individuals with prolonged respiratory symptoms, independent of PTB diagnosis. This is consistent with other studies of depression in primary care in Brazil.

Descriptors: Depression; tuberculosis; prevalence

Prevalence of and pathways to benzodiazepine use in Brazil: the role of depression, sleep, and sedentary lifestyle
Clarice S. Madruga; Thales L. Paim; Hamer N. Palhares; Andre C. Miguel; Luciana T.S. Massaro; Raul Caetano; Ronaldo R. Laranjeira

OBJECTIVE: This study aimed to determine the prevalence of benzodiazepine (BZD) use in Brazil and to investigate the direct and indirect effects of alcohol consumption, sedentary lifestyle (SL), depressive symptoms (DS), and sleep dissatisfaction (SD) on BZD use.
METHODS: The Second Brazilian Alcohol and Drugs Survey (II BNADS) used stratified cluster probabilistic sampling to select 4,607 individuals aged 14 years and older from the Brazilian household population.
RESULTS: The lifetime and 12-month prevalence of BZD use was 9.8 and 6.1%, respectively. Older participants (age 40 and older) and women had higher rates. Alcohol use disorder, DS, and SD were significantly more prevalent in BZD users. The parallel multiple mediator model showed a positive direct effect of alcohol consumption on BZD use, with significant positive indirect effects of SL, Sd, and DS as simultaneous mediators leading to higher BZD intake. Other statistically significant indirect pathways were DS alone, SD alone, and all of the above except SL.
CONCLUSION: The prevalence of BZD use in Brazil is high compared to that of other countries. Knowledge of the main risk factors and pathways to consumption can guide prevention initiatives and underlie the development of better tailored and effective treatment strategies.

Descriptors: Benzodiazepines; prevalence; epidemiology; path analysis; Brazil

Structural equation modeling of psychopathic traits in Chilean female offenders using the Self-Report Psychopathy-Short Form (SRP-SF) Scale: a comparison of gender-based item modifications versus standard items
Elizabeth Leon-Mayer; Joanna Rocuant-Salinas; Hedwig Eisenbarth; Jorge Folino; Craig Neumann

OBJECTIVE: To examine the utility of the Self-Report Psychopathy-Short Form (SRP-SF) to assess psychopathic traits in female offenders and to test gender-based item modifications.
METHOD: A South American sample of female offenders (n=210) was assessed with the Psychopathy Checklist-Revised (PCL-R); 110 subjects also completed the standard SRP-SF, while 109 completed a version with items rewritten to be more relevant for females. The underlying latent structure of the PCL-R and both versions of the SRP-SF were examined.
RESULTS: Most of the modified items showed higher average item responses. The PCL-R showed a stronger association with the modified SRP-SF than with the standard SRP-SF. The four-factor model showed very good fit in accounting for the PCL-R data, consistent with previous research. For both SRP-SF versions, the results indicated good model fit. Structural equation models were tested separately, in which a superordinate SRP-SF factor was set to predict a broad factor reflecting chronic misconduct. Both versions showed good model fit, and the SRP-SF superordinate factor significantly predicted a chronic misconduct factor.
CONCLUSIONS: Both versions of the SRP-SF adequately reflected psychopathic features in this female sample; the modified items added robustness to representation of these features.

Descriptors: Psychopathy; female offenders; PCL-R; self-report psychopathy scale

Efficacy of adjunctive Garcinia mangostana Linn (mangosteen) pericarp for bipolar depression: study protocol for a proof-of-concept trial
Melanie M. Ashton; Michael Berk; Chee H. Ng; Malcolm Hopwood; Seetal Dodd; Alyna Turner; Ellie Brown; Felice N. Jacka; Susan M. Cotton; Jon-Paul Khoo; Mary Lou Chatterton; Bianca E. Kavanagh; Sarah E. Nadjidai; Samantha L. Lo Monaco; Brian H. Harvey; Jerome Sarris; Gin S. Malhi; Nathan L. Dowling; Olivia M. Dean

OBJECTIVE: Bipolar depression is characterized by neurobiological features including perturbed oxidative biology, reduction in antioxidant levels, and a concomitant rise in oxidative stress markers. Bipolar depression manifests systemic inflammation, mitochondrial dysfunction, and changes in brain growth factors. The depressive phase of the disorder is the most common and responds the least to conventional treatments. Garcinia mangostana Linn, commonly known as mangosteen, is a tropical fruit. The pericarp's properties may reduce oxidative stress and inflammation and improve neurogenesis, making mangosteen pericarp a promising add-on therapy for bipolar depression.
METHODS: Participants will receive 24 weeks of either 1,000 mg mangosteen pericarp or placebo per day, in addition to their usual treatment. The primary outcome is change in severity of mood symptoms, measured using the Montgomery-Åsberg Depression Rating Scale (MADRS), over the treatment phase. Secondary outcomes include global psychopathology, quality of life, functioning, substance use, cognition, safety, biological data, and cost-effectiveness. A follow-up interview will be conducted 4 weeks post-treatment.
CONCLUSION: The findings of this study may have implications for improving treatment outcomes for those with bipolar disorder and may contribute to our understanding of the pathophysiology of bipolar depression.
CLINICAL TRIAL REGISTRATION: Australian and New Zealand Clinical Trial Registry, ACTRN12616000028404.

Descriptors: Garcinia mangostana; bipolar disorder; treatment; clinical trial; depression

Metabolic syndrome and psychiatric disorders: a population-based study
Fernanda Pedrotti Moreira; Karen Jansen; Taiane de A. Cardoso; Thaíse C. Mondin; Pedro V. Magalhães; Flavio Kapczinski; Luciano D.M. Souza; Ricardo A. da Silva; Jean Pierre Oses; Carolina D. Wiener

OBJECTIVE: To identify the association of metabolic syndrome (MetS) and psychiatric disorders in young adults in southern Brazil.
METHODS: This population based cross-sectional study involved a total of 1,023 young adults between the ages of 21 and 32 years. Current episodes of psychiatric disorders were assessed using the Mini International Neuropsychiatric Interview - Plus version. MetS was evaluated using the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATP III).
RESULTS: Of the 1,023 participants, 24.3% were identified with MetS, 13.5% were diagnosed with anxiety disorders, 7.5% with current depression, 3.9% with bipolar disorders and 10.1% were at risk of suicide. MetS was associated with ethnicity (p = 0.022), excess weight (p < 0.001), current anxiety disorders (p < 0.001), current mood disorders (bipolar disorder in mood episode and current depression) (p < 0.001), and suicide risk (p < 0.001).
CONCLUSIONS: MetS was associated with psychiatric disorders. Awareness of factors associated with MetS can help identify high-risk individuals and stimulate disease prevention and control programs, as well as lifestyle changes.

Descriptors: Metabolic syndrome; psychiatric disorders; mood disorders; anxiety disorders; suicide

Topography of 11C-Pittsburgh compound B uptake in Alzheimer's disease: a voxel-based investigation of cortical and white matter regions
Daniele de P. Faria; Fabio L. Duran; Paula Squarzoni; Artur M. CoutinhO; Alexandre T. Garcez; Pedro P. Santos; Sonia M. Brucki; Maira O. de Oliveira; Eduardo S. Trés; Orestes V. Forlenza; Ricardo Nitrini; Carlos A. Buchpiguel; Geraldo Busatto Filho

OBJECTIVE: To compare results of positron emission tomography (PET) with carbon-11-labeled Pittsburgh compound B (11C-PIB) obtained with cerebellar or global brain uptake for voxel intensity normalization, describe the cortical sites with highest tracer uptake in subjects with mild Alzheimer's disease (AD), and explore possible group differences in 11C-Pib binding to white matter.
METHODS: 11C-PIB PET scans were acquired from subjects with AD (n=17) and healthy elderly controls (n=19). Voxel-based analysis was performed with statistical parametric mapping (SPM).
RESULTS: Cerebellar normalization showed higher 11C-PIB uptake in the AD group relative to controls throughout the cerebral cortex, involving the lateral temporal, orbitofrontal, and superior parietal cortices. With global uptake normalization, greatest cortical binding was detected in the orbitofrontal cortex; decreased 11C-PIB uptake in white matter was found in the posterior hippocampal region, corpus callosum, pons, and internal capsule.
CONCLUSION: The present case-control voxelwise 11C-PIB PET comparison highlighted the regional distribution of amyloid deposition in the cerebral cortex of mildly demented AD patients. Tracer uptake was highest in the orbitofrontal cortex. Decreased 11C-PIB uptake in white-matter regions in this patient population may be a marker of white-matter damage in AD.

Descriptors: Amyloid PET imaging; Alzheimer's disease; statistical parametric mapping

Child and Adolescent Psychosocial Care Center service use profile in Brazil: 2008 to 2012
Grey Y. Ceballos; Cristiane S. Paula; Edith L. Ribeiro; Darci N. Santos

OBJECTIVE: To describe the service use profile of Child and Adolescent Psychosocial Care Centers (Centro de Atenção Psicossocial Infanto-Juvenil [CAPSi]) in Brazil regarding diagnostic categories, sociodemographic aspects, and care modalities between 2008 and 2012.
METHODS: A descriptive, ecological study was performed using data from the Unified Health System regarding high-complexity procedure authorizations (Autorização de Procedimentos de Alta Complexidade [APAC]) for the period from 2008-2012. The variables sex, age, diagnosis (F00-F99 of ICD-10), and type of care provided were examined. The data were processed using TabWin and STATA version 12.
RESULTS: A total of 837,068 records were examined, each representing one visit to CAPSi. Most visits were by male users (68.8%). The most common diagnoses were hyperkinetic disorders (13%), pervasive developmental disorders (12.4%), and conduct disorders (8.4%).
CONCLUSIONS: Behavioral and emotional disorders that usually appear during childhood or adolescence and psychological development disorders were frequent, with more than 50% of the latter comprising autism spectrum disorders. Regional differences were observed, with a higher presence of this diagnosis in the Southeast, while the North and Northeast had a high percentage of visits due to mental retardation.

Descriptors: Mental health problems; children/adolescents; epidemiology; mental health service

Early childhood maltreatment experience and later sexual behavior in Brazilian adults undergoing treatment for substance dependence
Alessandra Diehl; Jales Clemente; Sandra C. Pillon; Paulo R.H. Santana; Claudio J. da Silva; Jair de J. Mari

OBJECTIVE: To investigate the prevalence of early childhood maltreatment and associations with later sexual behavior among adult substance users.
METHODS: A cross-sectional study enrolled 134 substance dependents who sought outpatient care in São Paulo, Brazil. Childhood trauma prevalence was assessed using the Childhood Trauma Questionnaire (CTQ). The Sexual Addiction Screening Test (SAST), drug of choice (DOC), and sexual behavior were also investigated.
RESULTS: The sample was composed predominantly of single adult males (76.1%), with alcohol as the DOC (73.9%). Experiences of emotional neglect (88.1%), emotional abuse (80.6%), physical neglect (78.4%), physical abuse (64.2%), and sexual abuse (31.3%) were prevalent. Women were more likely to have been sexually abused (OR 2.9, 95%CI 1.15-7.61) and physically abused (OR 3.7, 95%CI 1.31-10.6) in childhood. Those who were sexually abused in adulthood were more likely to have suffered physical abuse in childhood (OR 6.9, 95%CI 1.45-11.8). The odds of having been sexually abused in childhood were higher among subjects who reported to have exchanged sexual favors for drugs (OR 5.7, 95%CI 1.35-9.64) and to have been sexually abused in adulthood (OR 6.1, 95%CI 5.2-12.36).
CONCLUSION: Physical and sexual abuse in childhood are highly prevalent in substance-dependent adults, and are associated with sexual revictimization and high-risk sexual behavior in adulthood.

Descriptors: Adult survivors of child abuse; child maltreatment; substance-related disorders; sexual behavior

Smaller left anterior cingulate cortex in non-bipolar relatives of patients with bipolar disorder
Marsal Sanches; Edilberto Amorim; Benson Mwangi; Giovana B. Zunta-Soares; Jair C. Soares

OBJECTIVE: Bipolar disorder (BD) is highly heritable. The present study aimed at identifying brain morphometric features that could represent markers of BD vulnerability in non-bipolar relatives of bipolar patients.
METHODS: In the present study, structural magnetic resonance imaging brain scans were acquired from a total of 93 subjects, including 31 patients with BD, 31 non-bipolar relatives of BD patients, and 31 healthy controls. Volumetric measurements of the anterior cingulate cortex (ACC), lateral ventricles, amygdala, and hippocampus were completed using the automated software FreeSurfer.
RESULTS: Analysis of covariance (with age, gender, and intracranial volume as covariates) indicated smaller left ACC volumes in unaffected relatives as compared to healthy controls and BD patients (p = 0.004 and p = 0.037, respectively). No additional statistically significant differences were detected for other brain structures.
CONCLUSION: Our findings suggest smaller left ACC volume as a viable biomarker candidate for BD.

Descriptors: Bipolar disorder; cingulate cortex; magnetic resonance imaging; endophenotypes

No evidence of attentional bias toward angry faces in patients with obsessive-compulsive disorder
Michele Skinazi, Maria A. de Mathis, Tatiana Cohab, Marina de Marco e Souza, Roseli G. Shavitt, Euripedes C. Miguel, Marcelo Q. Hoexter, Marcelo C. Batistuzzo

OBJECTIVE: Although attentional bias (AB) toward angry faces is well established in patients with anxiety disorders, it is still poorly studied in obsessive-compulsive disorder (OCD). We investigated whether OCD patients present AB toward angry faces, whether AB is related to symptom severity and whether AB scores are associated with specific OCD symptom dimensions.
METHOD: Forty-eight OCD patients were assessed in clinical evaluations, intelligence testing and a dot-probe AB paradigm that used neutral and angry faces as stimuli. Analyses were performed with a one-sample t-test, Pearson correlations and linear regression.
RESULTS: No evidence of AB was observed in OCD patients, nor was there any association between AB and symptom severity or dimension. Psychiatric comorbidity did not affect our results.
CONCLUSION: In accordance with previous studies, we were unable to detect AB in OCD patients. To investigate whether OCD patients have different brain activation patterns from anxiety disorder patients, future studies using a transdiagnostic approach should evaluate AB in OCD and anxiety disorder patients as they perform AB tasks under functional neuroimaging protocols.

Descriptors: Threat; anxiety; cognition; reaction time; emotion; attention

Prevalence of self-reported trauma In a sample of Iranian children Is low and unrelated to parents' education or current employment status
Morteza Shamohammadi; Maryam Salmanian; Mohammad-Reza Mohammadi; Dena Sadeghi Bahmani; Edith Holsboer-Trachsler; Serge Brand

OBJECTIVE: In Western countries, the prevalence of childhood trauma (CT) ranges from 15 to 25%. CT might be indirectly associated with lower parental socioeconomic status and educational attainments. The aims of this cross-sectional study were fourfold: to assess prevalence of CT in a large sample of Iranian children; to compare the Iranian prevalence rates with those of Western countries; to explore gender-specific patterns; and to explore possible socioeconomic predictors.
METHOD: The sample comprised 608 children (mean age 11.49 years, 51.5% females). All completed the Farsi version of the Trauma Symptoms Checklist for Children. Additionally, parents reported on their current employment status and highest educational level.
RESULTS: Trauma symptoms were reported by 20 of 295 boys and 23 of 313 girls. The overall prevalence was 7.1%. Child-reported trauma symptoms were not associated with parents' socioeconomic status or highest educational level. Compared to prevalence findings from U.S. national surveys (ranging from 15-25% of children and adolescents), the prevalence among 11- and 12-year-olds in the present study was considerably lower.
CONCLUSIONS: The overall prevalence of reported trauma symptoms among a large sample of Iranian children was unrelated to parents' socioeconomic status, and was lower than that reported in U.S. surveys.

Descriptors: Trauma symptoms; prevalence; socioeconomic status; education

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach
Leonardo Baldaçara; Flávia Ismael; Verônica Leite; Lucas A. Pereira; Roberto M. dos Santos; Vicente de P. Gomes JUnior; Elie L.B. Calfat; Alexandre P. Diaz; Cintia A.M. Perico; Deisy M. Porto; Carlos E. Zacharias; Quirino Cordeiro; Antonio Geraldo da Silva; Teng C. Tung

OBJECTIVE: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil.
METHODS: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools.
RESULTS: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree.
CONCLUSION: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint.

Descriptors: Environmental health; psychomotor agitation; aggression; emergency; mental disorders; patient care team; risk assessment; physical restraint; immobilization

From anatomy to function: the role of the somatosensory cortex in emotional regulation
Erika Kropf; Sabrina K. Syan; Luciano Minuzzi; Benicio N. Frey

Since the pioneering work of Penfield and his colleagues in the 1930s, the somatosensory cortex, which is located on the postcentral gyrus, has been known for its central role in processing sensory information from various parts of the body. More recently, a converging body of literature has shown that the somatosensory cortex also plays an important role in each stage of emotional processing, including identification of emotional significance in a stimulus, generation of emotional states, and regulation of emotion. Importantly, studies conducted in individuals suffering from mental disorders associated with abnormal emotional regulation, such as major depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety and panic disorders, specific phobia, obesity, and obsessive-compulsive disorder, have found structural and functional changes in the somatosensory cortex. Common observations in the somatosensory cortices of individuals with mood disorders include alterations in gray matter volume, cortical thickness, abnormal functional connectivity with other brain regions, and changes in metabolic rates. These findings support the hypothesis that the somatosensory cortex may be a treatment target for certain mental disorders. In this review, we discuss the anatomy, connectivity, and functions of the somatosensory cortex, with a focus on its role in emotional regulation.

Descriptors: Somatosensory cortex; emotional regulation; mental disorders