Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2017: 2.093
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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

Psychological distress among transgender people in Brazil: frequency, intensity and social causation - an ICD-11 field study
Maria I. Lobato; Bianca M. Soll; Angelo Brandelli Costa; Alexandre Saadeh; Daniel A.M. Gagliotti; Ana Fresán; Geoffrey Reed; Rebeca Robles

OBJECTIVE: To describe self-reported experiences of gender incongruence related to discomfort and body changes to be more congruent to the desired gender, and to examine whether experiences of psychological distress related to gender identity were more strongly related to the experience of gender incongruence per se or to experiences of social rejection.
METHODS: This field study used a structured interview design in a purposive sample of transgender adults (aged > 18 years or older) receiving health-care services in two main reference centers in Brazil.
RESULTS: A high proportion of participants (90.3%, n=93) reported experiencing psychological distress related to their gender identity and report having experienced social rejection related to their gender identity during the interview index period and that rejection by friends was the only significant predictor for psychological distress.
CONCLUSIONS: Gender incongruence variables were not significant predictors of distress. This result supports the recent changes proposed by the Word Health Organization in ICD-11 to move transgender conditions from the Mental and Behavioral Disorders chapter to a new chapter on Sexual Disorders and Conditions Related to Sexual Health.

Descriptors: ICD-11; diagnosis and classification; social and political issues

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

Aggression directed towards others vs. aggression directed towards the self: clinical differences between intermittent explosive disorder and nonsuicidal self-injury
Gustavo C. Medeiros; Liliana Seger-Jacob; Anna K. Garreto; Hyoun S. Kim; Emil F. Coccaro; Hermano Tavares

OBJECTIVE: To investigate the clinical differences between intermittent explosive disorder (IED) (disorder of aggression primarily directed towards others) and nonsuicidal self-injury (NSSI) (disorder of aggression predominantly directed towards the self) in order to better understand the different clinical subtypes of aggression.
METHODS: We used treatment-seeking samples to compare demographic and clinical correlates between 82 participants with IED and 55 participants with NSSI.
RESULTS: The IED group was older, more likely to be male, in a relationship, and employed than the NSSI group. With respect to clinical variables, the NSSI group had more severe depressive symptoms and more social adjustment difficulties. Regarding psychiatric co-morbidities, the IED group had higher rates of generalized anxiety disorder. On the other hand, the NSSI group had higher rates of major depressive disorder, agoraphobia, substance use disorder, and bulimia nervosa.
CONCLUSIONS: Individuals with NSSI may benefit from better management of psychiatric comorbidities, specifically depressive symptoms and social adjustment difficulties. Conversely, the treatment of individuals with IED may be improved by targeting comorbid generalized anxiety disorder. Our results provide important insight for the development of tailored interventions for specific subtypes of aggression.

Descriptors: Aggression; intermittent explosive disorder; nonsuicidal self-injury

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach
Leonardo Baldaçara; Alexandre P. Diaz; Verônica Leite; Lucas A. Pereira; Roberto M. dos Santos; Vicente de P. Gomes Júnior; Elie L.B. Calfat; Flávia Ismael; Cintia A.M. Périco; Deisy M. Porto; Carlos E.K. Zacharias; Quirino Cordeiro; Antônio Geraldo da Silva; Teng C. Tung

OBJECTIVE: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil.
METHODS: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature 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: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration.
CONCLUSION: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation.

Descriptors: Psychomotor agitation; aggression; tranquilizing agents; emergency; mental disorders

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

SIGMA-VB: Validity and reliability of the Brazilian Portuguese version of the Montgomery-Åsberg Depression Rating Scale using the Structured Interview Guide for the MADRS
Fernando Fernandes; Adriana Carneiro; Rodolfo N. Campos; Marcio G. Soeiro-de-Souza; Vivian B. Barros; Ricardo A. Moreno

OBJECTIVE: The Montgomery-Åsberg Depression Rating Scale (MADRS) is widely used to assess depression severity. The Structured Interview Guide for the MADRS (SIGMA) was created to standardize MADRS assessment. The objective of this study was to translate and validate the original SIGMA into a Brazilian Portuguese version (SIGMA-VB).
METHODS: We translated and cross-culturally validated the original SIGMA into the SIGMA-VB, and assessed its psychometric properties using data from 93 adult outpatients enrolled in the Integral Assessment in Unipolar Depression (AIUNI) trial. Participants were assessed by two raters on five visits over 8 weeks. We calculated multiple interrater reliability indexes for the SIGMa-VB and used the Hamilton Depression Hating Scale (HAM-D) for validation purposes.
RESULTS: According to the SIGMA-VB, participants had moderate depression at baseline followed by mild depression at 8 weeks. We found over 90% of correlation between scores attributed by different raters using the SIGMA-VB. Correlations between the SIGMA-VB and the HAM-D were above 66%.
CONCLUSION: Our findings confirm that the SIGMA-VB is a valid and reliable instrument to assess depression severity in clinical research and practice. Its interrater reliability was similar to that of a previously published Japanese version of the SIGMA.

Descriptors: Psychiatric status rating scales; depression; depressive disorder; validation studies as topic

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

Investigating the Spectra constellations of the Hierarchical Taxonomy of Psychopathology (HiTOP) model for personality disorders based on empirical data from a community sample
Giselle Pianowski,; Lucas de F. Carvalho,; Fabiano K. Miguel

OBJECTIVE: The Hierarchical Taxonomy of Psychopathology (HiTOP) posits that psychopathology is hierarchically structured. For personality disorder (PD) traits, there are five spectra: internalizing, thought disorder, disinhibited externalizing, antagonistic externalizing, and detachment. Empirical findings suggest a sixth group, compulsivity. In this research, we tried to recover the five HiTOP spectra, plus compulsivity, specifically for PD traits.
METHODS: The sample was composed of 4,868 Brazilians (54.9% women, age ranging from 18 to 70; mean = 25.7; SD = 9.64). All participants answered the Dimensional Clinical Personality Inventory 2 (IDCP-2), a self-report inventory for adults, developed in Brazil, for assessment of pathological personality traits.
RESULTS: Parallel analysis yielded up to nine factors. On exploratory structural equation modeling (E-SEM), the balance between interpretability and fit index suggested the six-factor solution as the best solution. The fit indexes for the confirmatory factor analysis were slightly less adjusted in comparison to the empirical model.
CONCLUSION: The hypothesis was confirmed, as we did find the groups proposed at the spectrum level of the HiTOP. We also found a compulsivity factor, encompassing the main traits from the conscientiousness dimension of IDCP-2, which is related to obsessive-compulsive PD. Finding the six groupings of traits in the HiTOP model contributes to the validity of this model, and confirms the existence of proposed spectra.

Descriptors: Keywords: Personality disorders; internal structure; diagnostic classification

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

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

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

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

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

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

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

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

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