Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2018: 2.440
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Suicide mortality among youth in southern Brazil: a spatiotemporal evaluation of socioeconomic vulnerability
Ana C. Alarcão; Cátia M. Dell' Agnolo; João R. Vissoci; Elias C.A. Carvalho; Catherine A. Staton; Luciano de Andrade; Kátia B. Fontes; Sandra M. Pelloso; Júlio C. Nievola; Maria D. Carvalho

OBJECTIVE: To conduct a geospatial analysis of suicide deaths among young people in the state of Paraná, southern Brazil, and evaluate their association with socioeconomic and spatial determinants.
METHODS: Data were obtained from the Mortality Information System and the Brazilian Institute of Geography and Statistics. Data on suicide mortality rates (SMR) were extracted for three age groups (15-19, 20-24, and 25-29 years) from two 5-year periods (1998-2002 and 2008-2012). Geospatial data were analyzed through exploratory spatial data analysis. We applied Bayesian networks algorithms to explore the network structure of the socioeconomic predictors of SMR.
RESULTS: We observed spatial dependency in SMR in both periods, revealing geospatial clusters of high SMR. Our results show that socioeconomic deprivation at the municipality level was an important determinant of suicide in the youth population in Paraná, and significantly influenced the formation of high-risk SMR clusters.
CONCLUSION: While youth suicide is multifactorial, there are predictable geospatial and sociodemographic factors associated with high SMR among municipalities in Paraná. Suicide among youth aged 15-29 occurs in geographic clusters which are associated with socioeconomic deprivation. Rural settings with poor infrastructure and development also correlate with increased SMR clusters.

Descriptors: Suicide; socioeconomic factors; spatial analysis; public health; epidemiology.

Lifetime prevalence, sociodemographic predictors, and comorbidities of oppositional defiant disorder: the National Epidemiology of Iranian Child and Adolescent Psychiatric disorders (IRCAP)
Mohammad Reza Mohammadi; Maryam Salmanian; Zahra Hooshyari; Alia Shakiba; Seyyed Salman Alavi; Ameneh Ahmadi; Ali Khaleghi; Hadi Zarafshan; Seyed Ali Mostafavi; Anita Alaghmand; Parviz Molavi; Javad Mahmoudi-Gharaei; Koorosh Kamali; Ahmad Ghanizadeh; Hedayat Nazari; Nasrin Sarraf; Ahmad Ahmadipour; Firoozeh Derakhshanpour; Forough Riahi; Atieh Golbon; Maryam Kousha; Aazam Sadat Heydari Yazdi; Mahin Eslami Shahrbabaki; Naser Hajian Motlagh; Houshang Amirian; Azizollah Mojahed; Arezou Kiani; Mohammad Ahmadpanah; Reza Dastjerdi; Nastaran Ahmadi

OBJECTIVE: This was the first national epidemiological study on oppositional defiant disorder (ODD) in Iran, which provided new information about the prevalence, comorbidities, and sociodemographic predictors of ODD.
METHODS: Data from a face-to-face household survey of 30,532 children and adolescents aged 6-18 years were collected from across all 31 provinces of Iran using a multistage cluster sampling design. The Persian version of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version (K-SADS-PL) was used in this study.
RESULTS: The lifetime prevalence of ODD was found to be 3.9%. ODD was significantly more common in boys than girls and appeared in late adolescence more frequently than in childhood. A lower prevalence of ODD was found among participants who lived in rural areas. ODD is highly likely to co-occur with attention deficit hyperactivity disorder, separation anxiety disorder, generalized anxiety disorder, and depressive disorders.
CONCLUSIONS: The findings of this national population-based study confirm and extend previous findings on the prevalence, comorbidities, and sociodemographic predictors of ODD.

Descriptors: Oppositional defiant disorder (ODD); comorbidity; prevalence; Iran.

Difficulties in activities of daily living are associated with stigma in patients with Parkinson's disease who are candidates for deep brain stimulation
Antônio G. da Silva; Vanessa P. Leal; Paulo R. da Silva; Fernando C. Freitas; Marcelo N. Linhares; Roger Walz; Leandro F. Malloy-Diniz; Alexandre P. Diaz; Antônio P. Palha

OBJECTIVE: Parkinson's disease (PD) is often accompanied by stigma, which could contribute to a worse prognosis. The objective of this study is to identify the variables associated with stigma in PD patients who are candidates for deep brain stimulation (DBS).
METHODS: We investigated sociodemographic and clinical variables associated with stigma in a sample of 54 PD patients indicated for DBS. The independent variables were motor symptoms assessed by the Movement Disorder Society‐sponsored revision of the Unified Parkinson Disease Rating Scale (MDS-UPDRS III), depressive symptoms measured by the Hospital Anxiety and Depression Scale, age, disease duration and the presence of a general medical condition. The Mobility, Activities of daily living and Emotional well-being domains of the 39-item Parkinson's Disease Questionnaire (PDQ-39) were also investigated as independent variables, and the Stigma domain of the PDQ-39 scale was considered the outcome variable.
RESULTS: After multiple linear regression analysis, activities of daily living remained associated with the Stigma domain (B = 0.42 [95%CI 0.003-0.83], p = 0.048). The full model accounted for 15% of the variance in the Stigma domain (p = 0.03).
CONCLUSIONS: Although causal assumptions are not appropriate for cross-sectional studies, the results suggest that ADL difficulties could contribute to greater stigma in PD patients with refractory motor symptoms who are candidates for DBS.

Descriptors: Activities of daily living; depressive symptoms; Parkinson's disease; quality of life; stigma.

Depression and quality of life in older adults on hemodialysis
Saulo B.V. de Alencar; Fábia M. de Lima; Luana do A. Dias; Victor do A. Dias; Anna C. Lessa; Jéssika M. Bezerra; Julianna F. Apolinário; Kátia C. de Petribu

OBJECTIVE: Depression is highly prevalent in hemodialysis patients, but few studies have evaluated older hemodialysis patients. The aim of this study was to evaluate the prevalence of depression, its associated factors and its impact on quality of life in an older population on hemodialysis.
METHODS: This was a cross-sectional study including 173 hemodialysis patients aged 60 years or older in Recife, Brazil. Depression was evaluated using the Mini-International Neuropsychiatric Interview when depressive symptoms (according to the 5-item Geriatric Depression Scale) were present. Quality of life was assessed with the Control, Autonomy, Self-realization and Pleasure Questionnaire (CASP-16). Data were also collected on sociodemographic, laboratory (albumin, parathormone, hemoglobin, and phosphorus) and dialysis (dialysis vintage, vascular access and hemodialysis adequacy) characteristics.
RESULTS: Depression was present in 22.5% of the sample. Depressed patients presented low CASP-16 quality of life scores (31.6 vs. 24.2, p < 0.001), twice the odds of albumin levels < 3.8 g/dL (OR 2.36; 95%CI 1.10-5.07; p = 0.027) and higher parathormone levels (OR 1.06; 95%CI 1.00-1.13; p = 0.05).
CONCLUSION: Older hemodialysis patients have a high prevalence of depression. Depressed patients presented poor quality of life, lower serum albumin and higher parathormone levels. Teams dealing with older hemodialysis patients should include depression and quality of life assessments in care protocols.

Descriptors: Depression; aging; hemodialysis; quality of life.

Self-injurious behavior and related mortality in children under 10 years of age: a retrospective health record study in Brazil
Paula Studart-Bottó; Davi F. Martins-Junior; Stella Sarmento; Lucas Argolo; Amanda Galvão-de-Almeida; Ângela Miranda-Scippa

OBJECTIVE: To describe and analyze data on self-injurious behavior (SIB) and related mortality in children under 10 years old in Brazil.
METHODS: A descriptive study was performed using secondary public health care data extracted from the Hospital Information System (Sistema de Informações Hospitalares, SIH) and Mortality Information System (Sistema de Informações sobre Mortalidade, SIM) in Brazil. The databases are available for online access at
RESULTS: In Brazil, according to SIH data, 11,312 hospitalizations of patients under 10 years of age were recorded from 1998 to 2018 as resulting from SIB (ICD-10 X60-X84 codes). Of these, 65 resulted in death. According to the SIM, from 1996 to 2016, 91 deaths related to SIB were recorded, 81 (89%) in children aged 5 to 9 years, nine (9.9%) in children aged 1 to 4 years, and one (1.1%) in a child below 1 year of age.
CONCLUSION: These results highlight the relevance of creating measures to better understand SIB and related mortality in this age group. They also reveal the vulnerability of children in Brazil and warrant further studies to address these issues.

Descriptors: Suicide; suicide attempt; children; self-harm; self-injurious behavior; suicidal behavior.

Neuroimaging adolescents with depression in a middle-income country: feasibility of an fMRI protocol and preliminary results
Lucas Battel; Johnna Swartz; Mauricio Anes; Pedro H. Manfro; Luis A. Rohde; Anna Viduani; Valeria Mondelli; Christian Kieling

OBJECTIVE: To test the feasibility and to present preliminary results of a neuroimaging protocol to evaluate adolescent depression in a middle-income setting.
METHODS: We assessed psychotropic medication-free adolescents (age range 14-16 years) with a diagnosis of major depressive disorder (MDD). Participants underwent a comprehensive clinical evaluation and both structural and functional magnetic resonance imaging (fMRI). In this pilot study, a preliminary single-group analysis of resting-state fMRI (rs-fMRI) data was performed, with a focus on the default mode network (DMN), cognitive control network (CCN), and salience network (SN).
RESULTS: The sample included 29 adolescents with MDD (mean age 16.01, SD 0.78) who completed the protocol. Only two participants were excluded due to MRI quality issues (head movement), and were not included in the analyses. The scans showed significant connectivity between the medial prefrontal cortex and posterior cingulate cortex (DMN), the ACC and anterior insula (SN), and the lateral prefrontal cortex and dorsal parietal cortex (CCN).
CONCLUSION: We demonstrated the feasibility of implementing a complex neuroimaging protocol in a middle-income country. Further, our preliminary rs-fMRI data revealed patterns of resting-state connectivity consistent with prior research performed in adolescents from high-income countries.

Descriptors: Depression; adolescent; neuroimaging.

At-risk drinking and current cannabis use among medical students: a multivariable analysis of the role of personality traits
Marcelo L. Schwarzbold; Gelline M. Haas; Rafael S. Barni; Patrícia Biava; Ana C. Momo; Thaís M. Dias; Tosin A. Ayodele; Alexandre P. Diaz; Flávio Vicente

OBJECTIVE: To explore the role of personality traits in at-risk drinking and current cannabis use among medical students.
METHODS: This cross-sectional study evaluated 707 medical students from two universities. Multiple logistic regression models for at-risk drinking and current cannabis use were constructed including sociodemographic, psychiatric, and personality variables.
RESULTS: At-risk drinking and current cannabis use were reported by 19.3% and 14.9% of participants, respectively. Models including Big Five measures showed associations of at-risk drinking with higher extraversion (p < 0.00001, adjusted odds ratio [AOR] = 1.9) and lower conscientiousness (p = 0.00001, AOR = 0.5); cannabis use was also associated with lower conscientiousness (p = 0.003, AOR = 0.6), besides higher openness to experience (p = 0.002, AOR = 1.9). Models including measures of the Behavioral Inhibition and Activation Systems scales (BIS/BAS) showed associations of at-risk drinking with lower BIS (p = 0.002, AOR = 0.9) and higher BAS fun-seeking (p = 0.0005, AOR = 1.2); cannabis use was also associated with higher BAS fun-seeking (p = 0.008, AOR = 1.2). Personality variables had modest effects on model fit.
CONCLUSION: Specific personality traits were independently associated with at-risk drinking and current cannabis use, albeit with modest effect sizes.

Descriptors: Alcohol drinking; alcohol abuse; marijuana use; personality; medical students.

Body self-image disturbances in women with prolactinoma
Helen S. Pereira; Erika C. Naliato; Aline B. Moraes; Monica R. Gadelha; Leonardo Vieira Neto; Renan M. Almeida; Antonio E. Nardi; Alice H. Violante

OBJECTIVE: To evaluate body dissatisfaction and distorted body self-image in women with prolactinoma.
METHODS: Body dissatisfaction and distorted body self-image were evaluated in 80 women with prolactinoma. All patients were in menacme, 34% had normal body mass index (BMI), and 66% were overweight. Most patients (56.2%) had normal prolactin (PRL) levels and no hyperprolactinemia symptoms (52.5%). The Body Shape Questionnaire (BSQ) was used to assess the patients' dissatisfaction with and concern about their physical form, and the Stunkard Figure Rating Scale (FRS) was used to assess body dissatisfaction and distorted body self-image. The patients were divided according to PRL level (normal vs. elevated) and the presence or absence of prolactinoma symptoms.
RESULTS: The normal and elevated PRL groups had similar incidences of body dissatisfaction and distorted body self-image. However, symptomatic patients reported a higher incidence of dissatisfaction than asymptomatic patients. Distorted body self-image was less common among symptomatic patients.
CONCLUSION: Symptomatic patients showed higher body dissatisfaction, but lower body self-image distortion. The presence of symptoms may have been responsible for increased body awareness. The perception of body shape could have triggered feelings of dissatisfaction compared to an ideal lean body. Therefore, a distorted body self-image might not necessarily result in body dissatisfaction in women with prolactinomas.

Descriptors: Prolactinoma; hyperprolactinemia; body image; distortion; dissatisfaction; BMI.

Incidence of depression in patients with hepatitis C treated with direct-acting antivirals
Elfi Egmond; Zoe Mariño; Ricard Navines; Giovanni Oriolo; Anna Pla; Concepció Bartres; Sabela Lens; Xavier Forns; Rocio Martin-Santos

OBJECTIVE: Depression has been associated with hepatitis C, as well as with its treatment with proinflammatory cytokines (i.e., interferon). The new direct-acting antiviral agents (DAAs) have minimal adverse effects and high potency, with a direct inhibitory effect on non-structural viral proteins. We studied the incidence and associated factors of depression in a real-life prospective cohort of chronic hepatitis C patients treated with the new DAAs.
METHODS: The sample was recruited from a cohort of 91 patients with hepatitis C, of both sexes, with advanced level of fibrosis and no HIV coinfection, consecutively enrolled during a 6-month period for DAA treatment; those euthymic at baseline (n=54) were selected. All were evaluated through the depression module of the Patient Health Questionnaire (PHQ-9-DSM-IV), at three time points: baseline, 4 weeks, and end-of-treatment.
RESULTS: The cumulative incidence (95%CI) of major depression and any depressive disorder during DAA treatment was 13% (6.4-24.4) and 46.3% (33.7-59.4), respectively. No differences were observed between those patients with and without cirrhosis or ribavirin treatment (p > 0.05). Risk factors for incident major depression during DAA treatment included family depression (relative risk 9.1 [1.62-51.1]), substance use disorder (11.0 [1.7-73.5]), and baseline PHQ-9 score (2.1 [1.1-3.1]).
CONCLUSIONS: The findings of this study highlight the importance of screening for new depression among patients receiving new DAAs, and identify potential associated risk factors.

Descriptors: Depression; direct-acting antivirals; DAA; hepatitis C; PHQ-9.

Biological bases for a possible effect of cannabidiol in Parkinson's disease
Nilson C. Ferreira-Junior; Alline C. Campos; Francisco S. Guimarães; Elaine Del-Bel; Patrícia M. da R. Zimmermann; Liberato Brum Junior; Jaime E. Hallak; José A. Crippa; Antonio W. Zuardi

OBJECTIVE: Current pharmacotherapy of Parkinson's disease (PD) is palliative and unable to modify the progression of neurodegeneration. Treatments that can improve patients' quality of life with fewer side effects are needed, but not yet available. Cannabidiol (CBD), the major non-psychotomimetic constituent of cannabis, has received considerable research attention in the last decade. In this context, we aimed to critically review the literature on potential therapeutic effects of CBD in PD and discuss clinical and preclinical evidence supporting the putative neuroprotective mechanisms of CBD.
METHODS: We searched MEDLINE (via PubMed) for indexed articles published in English from inception to 2019. The following keywords were used: cannabis; cannabidiol and neuroprotection; endocannabinoids and basal ganglia; Parkinson's animal models; Parkinson's history; Parkinson's and cannabidiol.
RESULTS: Few studies addressed the biological bases for the purported effects of CBD on PD. Six preclinical studies showed neuroprotective effects, while three targeted the antidyskinetic effects of CBD. Three human studies have tested CBD in patients with PD: an open-label study, a case series, and a randomized controlled trial. These studies reported therapeutic effects of CBD on non-motor symptoms.
CONCLUSIONS: Additional research is needed to elucidate the potential effectiveness of CBD in PD and the underlying mechanisms involved.

Descriptors: Cannabidiol; CBD; Parkinson; neurodegeneration; neuroprotection.

Combined influence of illness duration and medication type on visual sensitivity in schizophrenia
Natalia L. Almeida; Thiago P. Fernandes; Eveline H. Lima; Hemerson F. Sales; Natanael A. Santos

OBJECTIVE: Patients with schizophrenia have visual processing impairments. The main findings from the literature indicate that these deficits may be related to differences in paradigms, medications, and illness duration. This study is part of a large-scale study investigating visual sensitivity in schizophrenia. Here we aimed to investigate the combined effects of illness duration and antipsychotic use on contrast sensitivity function.
METHODS: Data were collected from 50 healthy controls and 50 outpatients with schizophrenia (classified according to illness duration and medication type) aged 20-45 years old. The contrast sensitivity function was measured for spatial frequencies ranging from 0.2 to 20 cycles per degree using linear sine-wave gratings.
RESULTS: Patients with an illness duration > 5 years had more pronounced deficits. Differences in the combined effects of illness duration and antipsychotic use were marked in patients on typical antipsychotics who had been ill > 10 years. No significant differences were found between typical and atypical antipsychotics in patients with an illness duration < 5 years.
CONCLUSION: Visual impairment was related to both long illness duration and medication type. These results should be tested in further studies to investigate pharmacological mechanisms.

Descriptors: Schizophrenia; contrast sensitivity function; illness duration; antipsychotics; psychiatry.

Megacities, migration and an evolutionary approach to bipolar disorder: a study of Sardinian immigrants in Latin America
Mauro G. Carta; Maria F. Moro; Martina Piras; Vanessa Ledda; Eleonora Prina; Serena Stocchino; Germano Orrù; Ferdinando Romano; Maria V. Brasesco; Rafael C. Freire; Antonio E. Nardi; Leonardo Tondo

OBJECTIVE: To determine whether people with a Sardinian genetic background who live in the megacities of South America have a higher frequency of hypomania than residents of Sardinia.
METHODS: A community survey of Sardinian immigrants was carried out in four Brazilian metropoles (n=218) and Buenos Aires (n=306). The results were compared with those of a study involving a similar methodology (Mood Disorder Questionnaire [MDQ] as a screening tool) conducted in seven Italian regions, including a sub-sample from Sardinia.
RESULTS: There was a higher prevalence of lifetime hypomania among Sardinians living in the Brazilian metropoles than among those living in Sardinia. This result was also consistent with Sardinian immigrants in Buenos Aires. After stratification by sex and age, the lifetime prevalence of MDQ scores ≥ 8 among Sardinians in South-American megacities and Sardinia was 8.6% vs. 2.9%, respectively (p < 0.0001).
CONCLUSIONS: The higher frequency of hypomania in migrant populations appears to favor an evolutionary view in which mood disorders may be a maladaptive aspect of a genetic background with adaptive characteristics.

Descriptors: Bipolar disorder; migration; evolutionary approach; megacities; Latin America.

Latin American and Spanish-speaking perspectives on the challenges of global psychiatry
Renato D. Alarcón; Fernando Lolas; Jair J. Mari; José Lázaro; Enrique Baca-Baldomero

The multi-faceted phenomenon known as globalization has a particular impact on the conceptual and practical development of mental health disciplines in general, and psychiatry in particular, across different world regions. To be theoretically and functionally effective, global psychiatry requires an integration of its different components. To such objective, and after a brief review of continental European and Anglo-Saxon contributions, this article examines the history, characteristics, and contributions of Latin/Iberian American and Spanish-speaking psychiatry, in order to substantiate its role in world psychiatry. The Latin American proper (including Portuguese-speaking Brazil), Spain, and U.S.-based Hispanic components are described, revealing an identity that is based on a humanistic tradition, a value-based, culturally-determined clinical approach to patient care, and a pragmatic adaptation of different treatment resources and techniques. These may constitute supportive elements of an instrumental inter-regional bond in the present and future of our discipline.

Descriptors: Latin American psychiatry; Spanish-speaking psychiatry; globalization; global mental health; Hispanic culture; identity.

Chronotype in bipolar disorder: an 18-month prospective study
Matias C. Melo; Raquel F. Garcia; Carolina F. de Araújo; José H. Luz; Pedro F. de Bruin; Veralice M. de Bruin

OBJECTIVE: Circadian dysregulation plays an important role in the etiology of mood disorders. Evening chronotype is frequent in these patients. However, prospective studies about the influence of chronotype on mood symptoms have reached unclear conclusions in patients with bipolar disorder (BD). The objective of this study was to investigate relationship between chronotype and prognostic factors for BD.
METHODS: At the baseline, 80 euthymic BD patients answered a demographic questionnaire and clinical scales to evaluate anxiety, functioning and chronotype. Circadian preference was measured using the Morningness-Eveningness Questionnaire, in which lower scores indicate eveningness. Mood episodes and hospitalizations were evaluated monthly for 18 months.
RESULTS: Among the BD patients, 14 (17.5%) were definitely morning type, 35 (43.8%), moderately morning, 27 (33.7%) intermediate (neither) and 4 (5%) moderately evening. Eveningness was associated with obesity or overweight (p = 0.03), greater anxiety (p = 0.002) and better functioning (p = 0.01), as well as with mood episodes (p = 0.04), but not with psychiatric hospitalizations (p = 0.82). This group tended toward depressive episodes (p = 0.06), but not (hypo)mania (p = 0.56).
CONCLUSION: This study indicated that evening chronotype predicts a poor prognostic for BD. It reinforces the relevance of treating rhythm disruptions even during euthymia to improve patient quality of life and prevent mood episodes.

Descriptors: Chronotype; circadian rhythm; bipolar disorder; prognosis.

The challenge of measurement in psychiatry: the lifetime accomplishments of Per Bech (1942-2018)
Marcelo P. Fleck; Danilo Carrozzino; Giovanni A. Fava


Bullying among adolescents: are the victims also perpetrators?
Andressa Reisen; Maria C. Viana; Edson T. dos Santos-Neto

OBJECTIVE: To analyze factors associated with the prevalence of maltreatment and bullying and to identify types of involvement (verbal, physical, social, sexual, cyberbullying) among high school students aged 15 to 19 years.
METHODS: A cross-sectional, school-based epidemiological survey was performed. The sample included 2,293 adolescents from public and private schools in the Greater Vitoria area (state of Espírito Santo, Brazil). A modified version of the Brazilian Portuguese Olweus Bully/Victim Questionnaire was used.
RESULTS: Among maltreatment behaviors, 43.3% of adolescents reported having been victims vs. 40.4% reporting to be aggressors. Among bullying behaviors, 41% reported victimization and 29.1% aggression. The most frequent types of bullying were verbal (victim = 33.8%, bully = 23.1%), social (victim = 21.8%, bully = 16.9%), and physical bullying (victim = 15.1%, bully = 8.7%). Of those reporting to be victims, 37.5% stated that they did not react as frequently as they were attacked. Almost half of the students (50.9%) identified themselves as victims, without practicing any type of aggression against another schoolmate. School network (public or private) and gender were significantly associated with victimization and aggression behaviors.
CONCLUSION: The adolescents identified as victims did not generally attack other students, i.e., did not identify themselves as perpetrators. The high prevalence of maltreatment and bullying detected in this study, especially the verbal, social, and physical types, underscores the need for interventions addressing bullying in schools.

Descriptors: Adolescent; bullying; adolescent behavior; schools; violence.

How do stress, sleep quality, and chronotype associate with clinically significant depressive symptoms? A study of young male military recruits in compulsory service
André C. Tonon; Alicia Carissimi; Regina L. Schimitt; Letícia S. de Lima; Fernanda dos S. Pereira; Maria Paz Hidalgo

OBJECTIVE: Although studies have shown an association between poor sleep and chronotype with psychiatric problems in young adults, few have focused on identifying multiple concomitant risk factors.
METHODS: We assessed depressive symptoms (Beck Depression Inventory [BDI]), circadian typology (Morningness-Eveningness Questionnaire [MEQ]), sleep quality (Pittsburgh Sleep Quality Index [PSQI]), perceived stress (Perceived Stress Scale [PSS]), social rhythm (Social Rhythm Metrics [SRM]), and salivary cortisol (morning, evening and night, n=37) in 236 men (all 18 years old). Separate analyses were conducted to understand how each PSQI domain was associated with depressive symptoms.
RESULTS: Depressive symptoms were more prevalent in individuals with higher perceived stress (prevalence ratio [PR] = 6.429, p < 0.001), evening types (PR = 2.58, p < 0.001) and poor sleepers (PR = 1.808, p = 0.046). Multivariate modeling showed that these three variables were independently associated with depressive symptoms (all p < 0.05). The PSQI items subjective sleep quality and sleep disturbances were significantly more prevalent in individuals with depressive symptoms (PR = 2.210, p = 0.009 and PR = 2.198, p = 0.008). Lower levels of morning cortisol were significantly associated with higher depressive scores (r = -0.335; p = 0.043).
CONCLUSION: It is important to evaluate multiple factors related to sleep and chronotype in youth depression studies, since this can provide important tools for comprehending and managing mental health problems.

Descriptors: Depression; circadian rhythm; circadian typology; cortisol; psychological stress; eveningness.

Correlation between CSF biomarkers of Alzheimer's disease and global cognition in a psychogeriatric clinic cohort'
Márcia Radanovic; Carlos A. Oshiro; Thiago Q. Freitas; Leda L. Talib; Orestes V. Forlenza

OBJECTIVE: The relationship between biomarkers of amyloid-beta aggregation (Aβ1-42) and/or neurodegeneration (Tau protein) in cerebrospinal fluid (CSF) and cognitive decline is still unclear. We aimed to ascertain whether CSF biomarkers correlate with cognitive performance in healthy and cognitively impaired subjects, starting from clinical diagnoses.
METHODS: We tested for correlation between CSF biomarkers and Mini-Mental State Examination (MMSE) scores in 208 subjects: 54 healthy controls, 82 with mild cognitive impairment (MCI), 46 with Alzheimer's disease (AD), and 26 with other dementias (OD).
RESULTS: MMSE correlated weakly with all CSF biomarkers in the overall sample (r = 0.242, p < 0.0006). Aβ1-42 and MMSE correlated weakly in MCI (r = 0.247, p = 0.030), and moderately in OD (r = 0.440, p = 0.027). t-Tau showed a weak inverse correlation with MMSE in controls (r = -0.284, p = 0.043) and MCI (r = -0.241, p = 0.036), and a moderate/strong correlation in OD (r = 0.665), p = 0.0003). p-Tau correlated weakly with MMSE in AD (r = -0.343, p = 0.026) and moderately in OD (r = -0.540, p = 0.0005). The Aβ1-42/p-Tau ratio had a moderate/strong correlation with MMSE in OD (r = 0.597, p = 0.001).
CONCLUSION: CSF biomarkers correlated best with cognitive performance in OD. t-Tau correlated weakly with cognition in controls and patients with MCI. In AD, only p-Tau levels correlated with cognitive performance. This pattern, which has been reported previously, seems to indicate that CSF biomarkers might not be reliable as indicators of disease severity.

Descriptors: Mild cognitive impairment; dementia; Alzheimer's disease; cerebrospinal fluid biomarkers.

Schneider's first-rank symptoms as predictors of remission in antipsychotic-naive first-episode psychosis
Fernando R. Malinowski; Brazilio de C. Tasso; Bruno B. Ortiz; Cinthia H. Higuchi; Cristiano Noto; Sintia I. Belangero; Rodrigo A. Bressan; Ary Gadelha; Quirino Cordeiro

OBJECTIVE: German psychiatrist Kurt Schneider proposed the concept of first-rank symptoms (FRS) of schizophrenia in 1959. However, their relevance for diagnosis and prediction of treatment response are still unclear. Most studies have investigated FRS in chronic or medicated patients. The present study sought to evaluate whether FRS predict remission, response, or improvement in functionality in antipsychotic-naive first-episode psychosis.
METHODS: Follow-up study of 100 patients at first episode of psychosis (FEP), with no previous treatment, assessed at baseline and after 2 months of treatment. The participants were evaluated with the standardized Positive and Negative Syndrome Scale (PANSS) and Global Assessment of Functioning (GAF) and for presence of FRS.
RESULTS: Logistic regression analysis showed that, in this sample, up to three individual FRS predicted remission: voices arguing, voices commenting on one's actions, and thought broadcasting.
CONCLUSION: Specific FRS may predict remission after treatment in FEP patients. This finding could give new importance to Kurt Schneider's classic work by contributing to future updates of diagnostic protocols and improving estimation of prognosis.

Descriptors: Schizophrenia; psychosis; antipsychotics; remission induction; treatment outcome.

Transcranial magnetic stimulation of the medial prefrontal cortex for psychiatric disorders: a systematic review
Rodrigo C. Marques; Larissa Vieira; Déborah Marques; Amaury Cantilino

OBJECTIVE: The medial prefrontal cortex (mPFC) is a highly connected cortical region that acts as a hub in major large-scale brain networks. Its dysfunction is associated with a number of psychiatric disorders, such as schizophrenia, autism, depression, substance use disorder (SUD), obsessive-compulsive disorder (OCD), and anxiety disorders. Repetitive transcranial magnetic stimulation (rTMS) studies targeting the mPFC indicate that it may be a useful therapeutic resource in psychiatry due to its selective modulation of this area and connected regions.
METHODS: This review examines six mPFC rTMS trials selected from 697 initial search results. We discuss the main results, technical and methodological details, safety, tolerability, and localization strategies.
RESULTS: Six different protocols were identified, including inhibitory (1 Hz) and excitatory (5, 10, and 20 Hz) frequencies applied therapeutically to patient populations diagnosed with major depressive disorder, OCD, autistic spectrum disorder, SUD, specific phobia, and post-traumatic stress disorder (PTSD). In the OCD and acrophobia trials, rTMS significantly reduced symptoms compared to placebo.
CONCLUSION: These protocols were considered safe and add interesting new evidence to the growing body of mPFC rTMS literature. However, the small number and low methodological quality of the studies indicate the need for further research.

Descriptors: Prefrontal cortex; medial prefrontal cortex; noninvasive transcranial stimulation; transcranial magnetic stimulation; depression; PTSD; autism spectrum disorder; substance-related disorders; phobic disorders.

Genome-wide DNA methylation profile in the peripheral blood of cocaine and crack dependents
Caroline Camilo; Mariana Maschietto; Henrique C. Vieira; Ana C. Tahira; Gisele R. Gouveia; Ana C. Feio dos Santos; André B. Negrão; Marcelo Ribeiro; Ronaldo Laranjeira; Homero Vallada; Helena Brentani

OBJECTIVE: Cocaine use disorders (CUDs) represent a major public health problem in many countries. To better understand the interaction between the environmental modulations and phenotype, the aim of the present study was to investigate the DNA methylation pattern of CUD patients, who had concomitant cocaine and crack dependence, and healthy controls.
METHODS: We studied DNA methylation profiles in the peripheral blood of 23 CUD patients and 24 healthy control subjects using the Illumina Infinium HumanMethylation450 BeadChip arrays.
RESULTS: Comparison between CUD patients and controls revealed 186 differentially methylated positions (DMPs; adjusted p-value [adjP] < 10-5) related to 152 genes, with a subset of CpGs confirmed by pyrosequencing. DNA methylation patterns discriminated CUD patients and control groups. A gene network approach showed that the EHMT1, EHMT2, MAPK1, MAPK3, MAP2K1, and HDAC5 genes, which are involved in transcription and chromatin regulation cellular signaling pathways, were also associated with cocaine dependence.
CONCLUSION: The investigation of DNA methylation patterns may contribute to a better understanding of the biological mechanisms involved in CUD.

Descriptors: Cocaine; crack cocaine; DNA methylation; drug dependence; epigenetics

Introducing the evidence-based population health tool of the Lower-Risk Cannabis Use Guidelines to Brazil
Benedikt Fischer; Monica Malta; Guilherme Messas; Marcelo Ribeiro

Cannabis is the most commonly used illegal drug, and is associated with well-documented adverse health outcomes, both acute and chronic. Cannabis use prevalence in Brazil is lower than in high-use regions in the Americas (e.g., North America), but concentrated among young people. Frameworks for cannabis control are increasingly shifting towards public health-oriented principles, with some countries undertaking respective policy reforms. These frameworks require a continuum of population-level interventions (e.g., prevention and treatment) including targeted prevention of adverse health outcomes among users. In this context, and based on examples from other health fields, an international expert group developed the evidence-based Lower-Risk Cannabis Use Guidelines (LRCUG), originally for Canada, including a set of 10 recommendations based on systematic data reviews and expert consensus methods. The LRCUG form a scientific population-health prevention tool to reduce adverse public health impacts for broad application among cannabis users. In Canada, the LRCUG have been formally endorsed and are supported by leading national health organizations and government authorities within the continuum of cannabis interventions. As the LRCUG are being internationalized, this paper introduces the LRCUG's concept and content - including their original recommendations translated into Portuguese - to the Brazilian context as an evidence-based population-level intervention tool for uptake, dissemination, and discussion. Sociocultural adaptation may be required for meaningful implementation.

Descriptors: Brazil; cannabis; health; policy; prevention; public health

Personality disorder and functioning in major depressive disorder: a nested study within a randomized controlled trial
Bianca E. Kavanagh; Lana J. Williams; Michael Berk; Alyna Turner; Henry J. Jackson; Mohammadreza Mohebbi; Buranee Kanchanatawan; Melanie M. Ashton; Chee H. Ng; Michael Maes; Lesley Berk; Gin S. Malhi; Nathan Dowling; Ajeet B. Singh; Olivia M. Dean

OBJECTIVE: This study aimed to determine if personality disorder (PD) predicted functional outcomes in patients with major depressive disorder (mDd).
METHODS: Data (n=71) from a double-blind, randomized, placebo-controlled 12-week trial assessing the efficacy of 200 mg/day adjunctive minocycline for MdD were examined. PD was measured using the Standardized Assessment of Personality Abbreviated Scale. Outcome measures included Clinical Global Impression - Improvement (CGI-I), Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q), Social and Occupational Functioning Scale (SOfAS), and Range of Impaired Functioning (RIFT). Analysis of covariance was used to examine the impact of PD (dichotomized factor [≥ 3] or continuous measure) on the outcome measures-treatment group correlation.
RESULTS: PD was identified in 69% of the sample. After adjusting for age, sex, and baseline scores for each of the outcome measures, there was no significant difference between participants with and without PD on week 12 scores for any of the outcome measures (all p > 0.14).
CONCLUSION: In this secondary analysis of a primary efficacy study, Pd was a common comorbidity among those with MDD, but was not a significant predictor of functional outcomes. This study adds to the limited literature on PD in randomized controlled trials for MDD.

Descriptors: Personality disorders; depression; clinical trial

Effects of mindfulness-based stress reduction combined with music therapy on pain, anxiety, and sleep quality in patients with osteosarcoma
Haizhi Liu; Xiurong Gao; Yuxin Hou

OBJECTIVES: To evaluate the effects of mindfulness-based stress reduction (MBSR) combined with music therapy (MT) on clinical symptoms in patients with osteosarcoma.
METHODS: Patients diagnosed with osteosarcoma were assessed for eligibility. A total of 101 patients were ultimately randomized into the intervention and control groups. Both groups received routine care. Eight sessions of MBSR and MT psychotherapy were conducted in the intervention group, while the control group received no psychological intervention. Patients were assessed regarding pain, anxiety, and sleep quality at two distinct stages: before and after the intervention.
RESULTS: There were no significant differences in sociodemographic and clinical parameters between the intervention and control groups at baseline. The intervention program significantly alleviated psychological and physiological complications in patients with osteosarcoma. Specifically, the study revealed that 8 weeks of the combined MBSR/MT intervention effectively reduced pain and anxiety scores and improved the quality of sleep in patients.
CONCLUSION: MBSR combined with MT significantly alleviated clinical symptoms, and could be considered a new, effective psychotherapeutic intervention for patients with osteosarcoma.

Descriptors: Osteosarcoma; mindfulness-based stress reduction (MBSR); music therapy (MT); pain; anxiety; sleep quality

Contributions of parenting styles and parental drunkenness to adolescent drinking
Carla R. Zuquetto; Emérita S. Opaleye; Marianne R. Feijó; Tatiana C. Amato; Cleusa P. Ferri; Ana R. Noto

OBJECTIVE: To estimate the association of parental drunkenness and parenting style with alcohol consumption among adolescents and the contributions of parental drunkenness and parenting style to the prevalence of binge drinking among adolescents.
METHOD: Cross-sectional survey of a representative sample of secondary students aged 13 to 18 from 27 Brazilian state capitals (n=17,028). Private and public schools were included. A self-report questionnaire collected data on adolescents' alcohol drinking behavior, parenting styles, and parenting and peer models of drunkenness.
RESULTS: Non-authoritative parenting style and parental drunkenness are associated with binge drinking among adolescents. Authoritarian, indulgent, and negligent parenting styles were associated with 1.50-, 2.51-, and 2.82-fold increases in prevalence of adolescent binge drinking, and parental drunkenness, with a 1.99-fold increase. The non-authoritative parenting style made a larger contribution than parental drunkenness to adolescent binge drinking.
CONCLUSIONS: Non-authoritative parenting style and parental drunkenness seem to play an important role in adolescents' binge drinking behavior. At the population level, parenting style appears associated with a greater contribution to this behavior among adolescents. Prevention strategies targeting parental drunkenness may be bolstered if a broader approach including parenting styles is in place.

Descriptors: Binge drinking; parenting styles; population attributable prevalence fractions; adolescence; alcohol

Evaluation of affective temperament and anxiety-depression levels in fibromyalgia patients: a pilot study
Selen Işık-Ulusoy

OBJECTIVE: Fibromyalgia (FM) patients have higher rates of depression and anxiety disorders than healthy controls. Affective temperament features are subclinical manifestations of mood disorders. Our aim was to evaluate the affective temperaments of FM patients and investigate their association with depression and anxiety levels and clinical findings.
METHODS: This cross-sectional study included FM patients and healthy controls. The Hospital Anxiety and Depression Scale (HADS) was used to determine patient anxiety and depression levels, and the Temperament Scale of Memphis, Pisa and San Diego, self-administered version was applied to assess affective temperaments in all subjects. Disease severity was assessed in FM patients with the Fibromyalgia Criteria and Severity Scales and the Fibromyalgia Impact Questionnaire (FIQ). Differences between groups were evaluated using Student's t-tests. Correlations among parameters were performed.
RESULTS: This study involved 38 patients with FM (30 female) and 30 healthy controls (25 female). Depressive, anxious and cyclothymic temperaments were significantly higher in FM patients than healthy controls. Statistically significant positive correlations were found between HADS depression score and all temperaments except hyperthymic, as well as between HADS anxiety score and cyclothymic and anxious temperaments. HADS depression and anxiety scores were correlated with symptom severity. We found a higher risk of depression and anxiety among FM patients with higher FIQ scores.
CONCLUSION: This study is the first to evaluate affective temperament features of FM patients. Evaluating temperamental traits in FM patients may help clinicians determine which patients are at risk for depression and anxiety disorders.

Descriptors: Fibromyalgia; anxiety; depression; affective temperament

Psychometric properties of the WHOQOL-SRPB BREF, Brazilian Portuguese version
Rogério R. Zimpel; Raquel G. Panzini; Denise R. Bandeira; Marcelo P. Fleck; Neusa S. da Rocha

OBJECTIVE: To test the reliability and the discriminant and convergent validity of the abbreviated Brazilian Portuguese World Health Organization's Quality of Life Instrument - Spirituality, Religion, and Personal Beliefs module (WHOQOL-SRPB BREF).
METHODS: In a sample of 404 individuals, we applied a general questionnaire, the WHOQOL-BREF, the long-form SRPB, the Brief Religious-Spiritual Coping Scale (RCOPE), and the Beck Depression Inventory (BDI). Priority was given to the 9-item SRPB assessment: its unidimensionality was tested through confirmatory factor analysis and Rasch analysis.
RESULTS: Confirmatory factor analysis of the 9-item SRPB assessment indicated an adjusted model with acceptable fit to data. In the Rasch analysis, general fit measures showed adequate performance. The 9-item SRPB assessment showed good internal consistency (alpha = 0.85), and could differentiate (discriminant validity) between religious and atheist/agnostic respondents (mean = 74.7±14.1 and 56.8615.5, respectively; t = 6.37; degrees of freedom [df] = 402; p < 0.0l) and between non-depressed and depressed respondents (mean = 76.5±12.9 and 67.1 ±16.5; t = 5.57; df = 190.5; p < 0.01). Correlations (convergent validity) were significant with the positive-RCOPE subscale (r = 0.58, p < 0.01) and the WHOQOL-BREF domains (Pearson coefficient ranging between 0.24 and 0.49; p < 0.01), but were in the negative direction with the negative-RCOPE subscale (r = -0.10, p < 0.05). Correlation with the long-form SRPB domain (r = 0.934) was almost perfect.
CONCLUSION: The Brazilian Portuguese 9-item SRPB has good psychometric properties and confirmed the findings of the long-form Brazilian Portuguese version and the abbreviated English version.

Descriptors: Spirituality; religiousness; spiritual QoL; WHOQOL-SRPB BREF; psychometrics

Predictors of quality of life in Brazilian medical students: a systematic review and meta-analysis
Ana C. Solis; Francisco Lotufo-Neto

OBJECTIVE: To examine predictors associated with quality of life (QoL) in Brazilian medical students.
METHODS: PubMed, PsycINFO, EMBASE, LILACS, and Google Scholar were searched for research articles in English or Portuguese published through August 2018. Observational studies that measured QoL with standard instruments were selected. Three instruments were used to evaluate QoL: the World Health Organization QoL questionnaires (WHOQOL-Bref and WHOQOL-100) and 36-item Short Form Health Survey (SF-36). Hedges' g was used to calculate effect sizes. A random-effects model was used in meta-analyses. PRISMA guidelines were followed.
RESULTS: The initial search retrieved 8,504 articles; 24 met the eligibility criteria for systematic review, and seven for meta-analyses of gender (n=3,402 students). Predictors of QoL such as gender, years of medical school(years of study), economic class, educational environment, academic efficacy, depression, burnout, resilience, empathic concern, sleep difficulties, chronic illness, body mass index, and leisure-time physical activity were identified in the systematic review. The most frequent predictors of QoL detected in Brazilian medical students were associated with gender and years of study.
CONCLUSIONS: Female medical students had lower QoL scores in the physical health and psychological domains of WHOQOL-Bref compared to male students. Specific interventions should be designed for this group as appropriate.

Descriptors: Quality of life; medical students; meta-analysis; systematic review; Brazilian

Efficacy and safety of paliperidone palmitate 3-month formulation in Latin American patients with schizophrenia: A subgroup analysis of data from two large phase 3 randomized, double-blind studies
Adam J. Savitz; Haiyan Xu; Srihari Gopal; Isaac Nuamah; Maju Mathews; Bernardo Soares

OBJECTIVE: To analyze the efficacy and safety of paliperidone palmitate 3-monthly (PP3M) in Latin American patients with schizophrenia vs. rest-of-world (ROW).
METHODS: We analyzed data from two multinational, double-blind (DB), randomized, controlled phase 3 studies including patients with schizophrenia (DSM-IV-TR) previously stabilized on PP1M/PP3M (open-label [OL] phase). Patients were randomized to PP3M or PP1M (noninferiority study A) and PP3M or placebo (study B) in DB phase. The subgroup analysis included Latin American (Argentina, Brazil, Colombia, Mexico) patients. Primary efficacy endpoints were relapse-free rates (study A) and time-to-relapse (study B).
RESULTS: In study A, 63/71 (88.7%) and in study B 38/43 (88.4%) Latin American patients completed the DB phase. In study A, relapse-free percentage was similar in Latin America (PP3M: 97%, PP1M: 100%) and ROW (PP3M: 91%, PP1M: 89%). In study B, median time-to-relapse was not estimable in the Latin American subgroup for either placebo or PP3M groups, nor for the ROW PP3M group; the median time-to-relapse in the ROW placebo group was 395 days. Caregiver burden improved in patients switching from oral antipsychotics (OL baseline) to PP3M/PP1M in DB phase (Involvement Evaluation Questionnaire score mean ± SD change, -9.4±15.16; p < 0.001). Treatment emergent adverse events with PP3M during DB phase were similar in Latin America (study A: 24/34 [70.6%]; study B: 15/21 [71.4%]) and ROW (study A: 318/470 [67.7%]; study B: 84/139 [60.4%]) subgroups.
CONCLUSION: PP3M was efficacious and showed no new safety concerns in patients with schizophrenia from Latin America, corroborating ROW findings.

Descriptors: Paliperidone palmitate once-monthly; paliperidone palmitate three-monthly; relapse prevention; schizophrenia

Semantic memory, but not education or intelligence, moderates cognitive aging: a cross-sectional study
Laiss Bertola; Rafaela T. Ávila; Maria Aparecida C. Bicalho; Leandro F. Malloy-Diniz

OBJECTIVE: Aging studies regularly assume that years of education are a protective factor for baseline cognition. In developing countries with specific sociocultural issues, this relationship may not work as expected, and an unmet need remains for alternative resilience factors. This study aimed to analyze different moderators for the relationship between aging and general cognition that could reflect better protective factors.
METHODS: One hundred and fourteen Brazilian older adults, deemed healthy by global cognition, absence of psychiatric symptoms, or neurological history, participated in this cross-sectional study. Moderators for the relationship between age and global cognition included education, intelligence, and occupational factors. Semantic memory was added as a protective factor reflecting culturally acquired conceptual knowledge.
RESULTS: As expected, age alone is a predictor of global cognitive scores; surprisingly, however, education, intelligence, and occupation were not moderators of the association. Semantic memory was a significant moderator (p = 0.007), indicating that knowledge acquired during life may be a protective factor.
CONCLUSION: In developing countries, the use of resilience factors based only on years of education may be misleading. Sociocultural issues influence the educational system and achievement and, consequently, affect the use of this simple measure. Resilience-factor studies should consider using crystallized abilities when studying populations with sociocultural particularities.

Descriptors: Semantics; protective factors; cognitive aging; educational status; developing countries; aging

Contextual risk factors of depression and suicidal thoughts in Brazilian adults: a multilevel analysis
Marina X. Carpena; Thais Martins-Silva; Francine S. Costa; Rodrigo Darley; Christian Loret de Mola

OBJECTIVE: To evaluate the association between social and health contextual variables, and between major depressive episodes (MDE) and suicidal thoughts in Brazilian adults.
METHODS: This population-based cross-sectional study used data from the 2013 National Health Survey (Pesquisa Nacional de Saúde). The Patient Health Questionnaire was used to evaluate the presence of MDE and suicidal thoughts. We used number of Family Health Strategy teams (FHS) per 20,000 state population, number of Psychosocial Care Centers (Centros de Atenção Psicossocial [CAPS]) per 1,000 state population, gross domestic product (GDP), and Gini index for each Brazilian state as contextual variables. Multilevel logistic regression models were used to calculate OR and the intraclass correlation coefficient (ICC).
RESULTS: Prevalence of MDE and suicidal thoughts was 4.1% (95%CI 3.8-4.4) and 3.8% (95%CI 3.5-4.1), respectively. Multilevel regression models showed an ICC of 1.1% for MDE (95%CI 0.5-2.3) and 1.3% for suicidal thoughts (95%CI 0.6-2.6). Neither GDP, Gini, FHS, or CAPS showed evidence of association with the outcomes.
CONCLUSIONS: In general, contextual variables, within each Brazilian state, do not seem to affect the prevalence of MDE and suicidal thoughts.

Descriptors: Depression; suicide; multilevel analysis; health service; economic index

Effects of lithium on inflammatory and neurotrophic factors after an immune challenge in a lisdexamfetamine animal model of mania
Giovana Bristot; Bruna M. Ascoli; Ellen Scotton; Luiza P. Géa; Bianca Pfaffenseller; Márcia Kauer-Sant'Anna

OBJECTIVE: To evaluate whether an animal model of mania induced by lisdexamfetamine dimesylate (LDX) has an inflammatory profile and whether immune activation by lipopolysaccharides (LPS) has a cumulative effect on subsequent stimuli in this model. We also evaluated the action of lithium (Li) on inflammatory and neurotrophic factors.
METHODS: Adult male Wistar rats were subjected to an animal model of mania. After the open-field test, they were given LPS to induce systemic immune activation. Subsequently, the animals' blood was collected, and their serum levels of brain-derived neurotrophic factor and inflammatory markers (tumor necrosis factor [TNF]-α, interleukin [IL]-6, IL-1β, IL-10, and inducible nitric oxide synthase [iNOS]) were measured.
RESULTS: LDX induced hyperactivity in the animals, but no inflammatory marker levels increased except brain-derived neurotrophic factor (BDNF). Li had no effect on serum BDNF levels but prevented iNOS levels from increasing in animals subjected to immune activation.
CONCLUSION: Although Li prevented an LPS-induced increase in serum iNOS levels, its potential antiinflammatory effects in this animal model of mania were conflicting.

Descriptors: Bipolar disorder; mania; lithium; inflammation; lisdexamfetamine dimesylate

Pharmacokinetics of antidepressants in patients undergoing hemodialysis: a narrative literature review
Juliana L. Constantino; Vilma A. Fonseca

We conducted a narrative literature review on studies that specifically addressed the pharmacokinetics of antidepressants in patients on hemodialysis. The search included the MEDLINE, LILACS, and Web of Knowledge databases and combined Medical Subject Headings and free-text search terms for chronic kidney disease, end-stage renal disease, renal replacement therapy, depression, and antidepressants; it was limited to studies conducted in humans, with no language or time constraints. The search yielded 212 studies. After screening titles and abstracts, 32 studies were read in full and 11 ultimately met the inclusion criteria and were included in the review. Most of the studies showed no difference in the pharmacokinetics of antidepressant drugs between patients with normal renal function and patients undergoing hemodialysis. However, studies with fluvoxamine and amitriptyline showed that variations in albumin levels might affect serum concentrations of these agents. The included studies have several limitations, and there are many obstacles to the adequate treatment of depression in patients undergoing hemodialysis. Further studies on this topic are needed to support proper treatment of these patients, improving their quality of life and reducing mortality.

Descriptors: Antidepressive agents; depressive disorder; renal dialysis; pharmacokinetics; renal insufficiency, chronic

Suicidal behavior among substance users: data from the Second Brazilian National Alcohol and Drug Survey (II BNADS)
Renata R. Abdalla; André C. Miguel; Elisa Brietzke; Raul Caetano; Ronaldo Laranjeira; Clarice S. Madruga

OBJECTIVE: To investigate the prevalence rates of suicidal ideation (SI) and suicide attempts (SA) and their association with substance use in a nationally representative sample of Brazilians.
METHODS: The Second Brazilian National Alcohol and Drug Survey (II BNADS) is a household crosssectional survey that investigated the consumption of psychotropic drugs and associated risk factors. This national probability sample survey used a multistage cluster design to select 4,607 participants aged 14 or older and had a total response rate of 77%. Illegal drug use, SI and SA were obtained by confidential self-report assessment.
RESULTS: SI and SA were reported by 9.9 and 5.4% of the sample, respectively. This prevalence was 20.8 and 12.4% among individuals with alcohol use disorders (AUD), 31.5 and 16.5% among cannabis users and 40.0 and 20.8% among cocaine users. After adjusting for demographic characteristics, tobacco use, family history of suicide and depression, both SI and SA were positively associated with AUD, cannabis and cocaine use.
CONCLUSION: AUD, cannabis and cocaine use were significantly associated with SI and SA, even after the adjustments. Public health initiatives targeting suicide prevention should consider including assessment and management of substance misuse, and therapeutic approaches to substance misuse should include assessment of suicidality.

Descriptors: Suicidal ideation; suicide attempts; substance abuse; alcohol misuse

Development and psychometric evaluation of the Mandarin Chinese version of the Yale-Brown Obsessive-Compulsive Scale - Second Edition
Chen C. Zhang; Hengfen Gong; Yingying Zhang; Haiyan Jin; Yong Yang; Bin Li; Yongchao Li; Xiao Luo; Wenjuan Liu; Fang Fang; Bin Li; Bomin Sun; Terri Fletcher; Valerie La Buissonnière-Ariza; Wayne K. Goodman; Eric A. Storch

OBJECTIVE: To examine the psychometric properties of the Chinese version of the Yale-Brown Obsessive Compulsive Scale - Second Edition (Y-BOCS-II).
METHOD: A total of 86 adults with a primary diagnosis of obsessive-compulsive disorder (OCD), ranging in age from 15 to 78 years, participated in the study. Participants were administered the Y-BOCS-II by a trained clinician who also rated overall illness severity on two additional measures. Patients completed the Obsessive Compulsive Inventory-Revised and Depression Anxiety Stress Scale-21.
RESULTS: Results indicated high internal consistency and fair 1-week test retest reliability. The Y-BOCS-II scales correlated strongly with clinician-rated obsessive-compulsive severity and modestly with self-reported obsessive-compulsive symptom frequency and distress. The relationship between Y-BOCS-II total score and depressive and anxiety symptoms was strong, which may reflect high rates of comorbid conditions in this sample or the linkage between obsessive-compulsive symptom severity and distress. Factor analysis demonstrated a two-factor structure consisting of obsession and compulsion factors, with interference due to obsessions cross-loading.
CONCLUSIONS: Overall, these results support the use of the Y-BOCS-II among individuals from China. Future study by an independent group is necessary to replicate these findings, as well as investigate interrater reliability and treatment sensitivity.

Descriptors: Obsessive-compulsive disorder; assessment; reliability; treatment

Psychological morbidity is the main predictor of quality of life among caregivers of individuals in first-episode psychosis: data from a year-long longitudinal study in Brazil
Rita de C. Jorge; Hugo Cogo-Moreira; Ary G. Araripe Neto; Ana C. Chaves

OBJECTIVE: To investigate quality of life (QoL) and QoL predictors among caregivers of individuals in first-episode psychosis (FEP).
METHODS: This longitudinal study investigated predictors of QoL in caregivers of 80 individuals in FEP over a 1-year follow-up period, measured using a single component extracted from the 36-item Short-Form Health Survey (SF-36).
RESULTS: Mediation analysis demonstrated that, at 1 year, high scores in the Self-Report Questionnaire (SRQ-20) were associated with high scores on the negative sub-scale of the Experience of Caregiving Inventory (ECI), which was also associated with low scores in the Essential Quality of Life (Essential QoL) component extracted from the SEF-36. Clinically, the resulting association indicates that depression and anxiety symptoms in caregivers at baseline are predictors of their 1-year quality of life, based on self-assessment of the caregiving experience.
CONCLUSION: Supporting an individual in FEP can have a negative impact on QoL. Maintaining caregivers' mental health and subjective evaluation of the caregiving experience must be primary goals of FEP services. Complementary studies of FEP caregivers' QoL can support the design of personalized interventions in the near future.

Descriptors: Psychotic disorders; caregivers; quality of life

The association between adolescent suicide rates and socioeconomic indicators in Brazil: a 10-year retrospective ecological study
Denisse Jaen-Varas; Jair J. Mari; Elson Asevedo; Rohan Borschmann; Elton Diniz; Carolina Ziebold; Ary Gadelha

OBJECTIVE: To examine suicide rates among adolescents from six large cities in Brazil and to analyze the relationship between adolescent suicide rates and socioeconomic indicators between 2006 and 2015.
METHODS: Generalized estimating equation models were used to assess the impact of socioeconomic factors - including social inequality and unemployment rates - on adolescent suicide rates.
RESULTS: The rate of adolescent suicide increased by 24% over the course of the study period. Social inequality (assessed using the Gini index), was positively associated with overall adolescent suicide rates (β = 10.68; 95%CI = 2.32-19.05; p ≤ 0.012). After disaggregating the findings by age (10-14 and 15-19 years), social inequality was associated with suicide rate only for adolescents aged 15-19 years (β = 9.63; 95%CI = 2.31-16.96; p p 0.005). Disaggregating these findings by sex, the association with economic variables became significant only among females. Males had a higher overall suicide rate than females, and the highest rate was observed in male adolescents aged 15-19 years. Higher levels of unemployment were associated with higher suicide rates.
CONCLUSION: Our findings suggest that socioeconomic indicators, particularly unemployment and social inequality, are relevant social determinants of suicide in adolescence.

Descriptors: Adolescent; suicide; socioeconomic factors; unemployment; inequality

Trends in suicide rates in Brazil from 1997 to 2015
Cássio D. Rodrigues; Débora S. de Souza; Henrique M. Rodrigues; Thais C.R.O. Konstantyner

OBJECTIVES: To analyze time trends of suicide rates in Brazil overall and in Brazilian states and compare the estimated suicide rates projected for 2020 with the World Health Organization (WHO) Mental Health Action Plan target.
METHODS: This was an ecological time-series study from 1997 to 2015, stratified by Brazilian states, specific age groups, and sex. Data were obtained from the Mortality Information System (Sistema de Informações sobre Mortalidade [SIM]) of the Brazilian Ministry of Health. Polynomial regression models were used to analyze the trends in suicide rates and to project suicide rates for 2020.
RESULTS: Considering 224 units of analysis, 21 (9.4%) showed a decreasing trend, 108 (48.2%) were stable, and 95 (42.4%) showed an increasing trend. Thus, 67% of units of analysis will not meet the WHO target in 2020. Mean suicide rates were higher in males than in females. People aged 60 years and older presented the highest suicide rates, while 84.7% of total deaths by suicide occurred among 15-to-59-year-olds.
CONCLUSION: Overall, 90.6% of units of analysis had a stable or increasing trend in suicide rates from 1997 to 2015. If these trends remain, most of Brazil will fail to achieve the WHO-recommended reduction in suicide rates by 2020.

Descriptors: Suicide; epidemiology; community mental health; public health; time series

The latent structure of the Young Schema Questionnaire-Short Form
William Sperb; Jandilson A. da Silva; Hugo Cogo-Moreira; Diogo R. Lara; Hudson W. de Carvalho

OBJECTIVE: The current study aimed to examine the latent structure of a web-based, Brazilian Portuguese version of the Young Schema Questionnaire-Short Form (YSQ-SF).
METHOD: The sample consisted of 15,557 adult participants - 4,702 men and 10,855 women - with age ranging from 18 to 60 years. Confirmatory factor analysis was used to test the a priori conceptual 15-factor model presumed to underlie the YSQ-SF item set.
RESULTS: Most items displayed high levels of reliability (factor loadings greater than 0.7) and low liability to random measurement error (residual variances below 0.02), indicating that the a priori YSQ-SF factor structure is adequate.
DISCUSSION: These findings offer empirical evidence supporting YSQ-SF construct validity and, consequently, its application in adults.

Descriptors: Young Schema Questionnaire; schema therapy; construct validity; web survey; structural equation analysis

Sociodemographic, behavioral, and health-related risk factors for depression among men and women in a southern Brazilian city
Marina X. Carpena; Samuel C. Dumith; Christian Loret de Mola; Lucas Neiva-Silva

OBJECTIVE: To assess the prevalence of depression and sociodemographic, behavioral, and health-related risk factors therefor in a southern Brazilian city.
METHODS: Population-based, cross-sectional study of adults from Rio Grande, state of Rio Grande do Sul, Brazil. Individuals (n=1,295) were selected using a multistage sampling procedure. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for major depressive episodes (MDEs). We used a conceptual causal framework to organize and assess risk factors for MDE and calculated prevalence ratios (PR) using regression models.
RESULTS: The prevalence of MDE was 8.4% (95%CI 6.0-10.7) for men and 13.4% (95%CI 11.0-15.8) for women. For men, physical inactivity (PR 2.34, 95%CI 1.09-5.00) and perceived stress (PR 20.35, 95%CI 5.92-69.96) were associated with MDe. In women, MDE prevalence was higher among those in the first tertile of economic index (PR 2.61, 95%CI 1.53-4.45), with 0-8 years of schooling (PR 2.25, 95%CI 1.24-4.11), alcohol users (PR 1.91, 95%CI 1.21-3.02), those physically inactive (PR 2.49, 95%CI 1.22-5.09), with the highest perceived stress (PR 9.17, 95%CI 3.47-24.23), with another mental disorder (PR 1.85, 95%CI 1.32-2.59), and with more noncommunicable diseases (PR 1.85, 95%CI 1.06-3.22).
CONCLUSION: Women had a higher prevalence of depression, and socioeconomic disadvantages were important for the occurrence of MDE; however, for men, only physical inactivity and stress were important predictors, suggesting possible different causal pathways for each sex.

Descriptors: Keywords: Depression; mood disorders; epidemiology; mental health; sex

Sociodemographic factors associated with smoking risk perception in adolescents in São Paulo, Brazil
Gabriela A. Wagner; Zila M. Sanchez; Thiago M. Fidalgo; Sheila C. Caetano; Hannah Carliner; Silvia S. Martins

OBJECTIVE: We examined the sociodemographic factors associated with smoking risk perceptions (SRP) in youth living in two very different neighborhoods in the city of São Paulo, Brazil: a middle-class central area (Vila Mariana) and a poor outer-city area (Capão Redondo).
METHODS: A cross-sectional survey was conducted with 180 public school-attending youth (all aged 12 years) and their parents. SRP was evaluated through self-reports. Weighted multinomial logistic regression was used to examine factors associated with SRP.
RESULTS: Smoking was considered a high-risk behavior by 70.9% of adolescents. There were significant differences in SRP associated with socioeconomic status (SES) and maternal smoking status. Having a non-smoking mother was positively associated with perceiving smoking as having low to moderate risk versus no risk (OR=3.91 [95%CI 1.27-12.02]). Attending school in Capão Redondo was associated with perceiving smoking as having high risk compared to no risk (OR=3.00 [95%CI 1.11-8.12]), and low SES was negatively associated with perceiving at least some risk in smoking versus perceiving no risk in this behavior.
CONCLUSIONS: Youth whose mothers smoke appear to have lower SRP than those whose mothers do not smoke. Living in a poor outer-city area was associated with higher SRP.

Descriptors: Keywords: Tobacco; public school; neighborhoods; Brazil