Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2017: 2.093
Fully open access
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Current issue 4, Volume 34 - Oct/Nov/Dec/2012


1 - Editors' Note
Marcelo Q. Hoexter; Leonardo F. Fontenelle; Tais Moriyama; João Quevedo; Marcos Hortes Nisihara Chagas; Guilherme V. Polanczyk; José Alexandre S. Crippa
Pages: 369 - 370


2 - Population ageing in Latin America: dementia and related disorders
Cleusa P. Ferri
Pages: 371 - 374


3 - Bringing melancholia out of the shadows
Gordon Parker
Pages: 375 - 378


4 - Treatment-resistant depression increases health costs and resource utilization
Beatrice Alinka Lepine; Ricardo Alberto Moreno; Rodolfo Nunes Campos;; Bernard François Couttolenc
Pages: 379 - 388

OBJECTIVE: Major Depressive Disorder (MDD) is a debilitating condition with a marked social impact. The impact of MDD and Treatment-Resistant Depression (TRD+) within the Brazilian health system is largely unknown. The goal of this study was to compare resource utilization and costs of care for treatment-resistant MDD relative to non-treatment-resistant depression (TRD-).
METHODS: We retrospectively analyzed the records of 212 patients who had been diagnosed with MDD according to the ICD-10 criteria. Specific criteria were used to identify patients with TRD+. Resource utilization was estimated, and the consumption of medication was annualized. We obtained information on medical visits, procedures, hospitalizations, emergency department visits and medication use related or not to MDD.
RESULTS: The sample consisted of 90 TRD+ and 122 TRD- patients. TRD+ patients used significantly more resources from the psychiatric service, but not from non-psychiatric clinics, compared to TRD- patients. Furthermore, TRD+ patients were significantly more likely to require hospitalizations. Overall, TRD+ patients imposed significantly higher (81.5%) annual costs compared to TRD- patients (R$ 5,520.85; US$ 3,075.34 vs. R$ 3,042.14; US$ 1,694.60). These findings demonstrate the burden of MDD, and especially of TRD+ patients, to the tertiary public health system. Our study should raise awareness of the impact of TRD+ and should be considered by policy makers when implementing public mental health initiatives.

Descriptors: Depression; Treatment Resistance; Resource Utilization; Treatment Costs; Hospital Costs.

5 - Validation of the Brazilian Portuguese version of the Beck Depression Inventory-II in a community sample
Marcio Henrique Gomes-Oliveira; Clarice Gorenstein; Francisco Lotufo Neto; Laura Helena Andrade; Yuan Pang Wang
Pages: 389 - 394

BACKGROUND: The Beck Depression Inventory (BDI) is used worldwide for detecting depressive symptoms. This questionnaire has been revised (1996) to match the DSM-IV criteria for a major depressive episode. We assessed the reliability and the validity of the Brazilian Portuguese version of the BDI-II for non-clinical adults.
METHODS: The questionnaire was applied to 60 college students on two occasions. Afterwards, 182 community-dwelling adults completed the BDI-II, the Self-Report Questionnaire, and the K10 Scale. Trained psychiatrists performed faceto- face interviews with the respondents using the Structured Clinical Interview (SCID-I), the Montgomery-Åsberg Depression Scale, and the Hamilton Anxiety Scale. Descriptive analysis, signal detection analysis (Receiver Operating Characteristics), correlation analysis, and discriminant function analysis were performed to investigate the psychometric properties of the BDI-II.
RESULTS: The intraclass correlation coefficient of the BDI-II was 0.89, and the Cronbach's alpha coefficient of internal consistency was 0.93. Taking the SCID as the gold standard, the cut-off point of 10/11 was the best threshold for detecting depression, yielding a sensitivity of 70% and a specificity of 87%. The concurrent validity (a correlation of 0.63-0.93 with scales applied simultaneously) and the predictive ability of the severity level (over 65% correct classification) were acceptable.
CONCLUSION: The BDI-II is reliable and valid for measuring depressive symptomatology among Portuguese-speaking Brazilian non-clinical populations.

Descriptors: Depression; Psychometric Scales; Validity; Beck Depression Inventory; Brazil.

6 - Sociodemographic and personal factors related to depressive symptomatology in the Mexican population aged 12 to 65
Clara Fleiz Bautista; Jorge Villatoro Velázquez; María Elena Medina Mora Icaza; Midiam Moreno López; María de Lourdes Gutiérrez López; Natania Oliva Robles
Pages: 395 - 404

OBJECTIVE: To describe the prevalence of depressive symptoms in the Mexican population, aged 12 to 65 years, by identifying the main related socio-demographic and personal factors.
METHODS: Data are drawn from the National Survey on Addictions 2008 (ENA 2008), a random, probabilistic, multistage study. A randomly selected sub-sample of 22,962 persons answered the section on depressive symptomatology, measured with the Center for Epidemiologic Studies Depression Scale (CES-D).
RESULTS: The total prevalence for depressive symptomatology was 5.1%; the prevalence was 7.5% for women and 2.5% for men. For women, more evidence of depressive symptoms was seen in the central region, whereas for men, symptoms were homogeneous across the country. Factors related to the presence of depressive symptoms include being divorced (in women) or widowed (in men), having lower educational attainment, perceiving one's place of residence as unsafe, displaying alcohol abuse or dependence, being a regular drug consumer (in men) and having been sexually abused (males and females).
CONCLUSIONS: The regional distribution of depressive symptomatology in women indicates the need for region-specific prevention programs that take into account the different social problems that affect women's emotional well-being. More research is also needed to support the early identification and intervention of men suffering from depression.

Descriptors: Depressive Symptomatology; Sociodemographic and Personal Factors; Survey.

7 - Burnout in familial caregivers of patients with dementia
Annibal Truzzi; Letice Valente; Ingun Ulstein; Eliasz Engelhardt; Jerson Laks; Knut Engedal
Pages: 405 - 412

OBJECTIVES: Familial caregivers of demented patients suffer from high levels of burden of care, but the literature is sparse regarding the prevalence and predictors of burnout in this group. Burnout is composed of three dimensions: emotional exhaustion (EE), depersonalization (DP) and reduced personal accomplishment (RPA). We aimed to investigate the associations between burnout dimensions and the caregivers' and patients' sociodemographic and clinical characteristics.
METHODS: This study is cross-sectional in design. Caregivers (N = 145) answered the Maslach Burnout Inventory, Beck Depression Inventory, Beck Anxiety Inventory and a Sociodemographic Questionnaire. Patients (N = 145) were assessed with the Mini Mental State Examination, Functional Activities Questionnaire, Neuropsychiatric Inventory, and Clinical Dementia Rating Scale.
RESULTS: High levels of EE were present in 42.1% of our sample, and DP was found in 22.8%. RPA was present in 38.6% of the caregivers. The caregivers' depression and the patients' delusions remained the significant predictors of EE.
CONCLUSIONS: The presence of caregiver depression and patient delusions should always be part of the multidisciplinary evaluation of dementia cases.

Descriptors: Caregiver; Burden of Care; Burnout; Depression; Dementia.

8 - Psychosocial and clinical predictors of retention in outpatient alcoholism treatment
João Maria Corrêa Filho; Danilo Antonio Baltieri
Pages: 413 - 421

OBJECTIVE: One of the factors associated with low rates of compliance in the treatment for alcoholism seems to be the intensity of craving for alcohol. This study aimed to evaluate the associations between alcohol craving and biopsychosocial addiction model-related variables and to verify whether these variables could predict treatment retention.
METHODS: The sample consisted of 257 male alcoholics who were enrolled in two different pharmacological trials conducted at the Universidade de São Paulo in Brazil. Based on four factors measured at baseline - biological (age, race, and family alcoholism), psychiatric (depression symptoms), social (financial and marital status), and addiction (craving intensity, severity of alcohol dependence, smoking status, drinking history, preferential beverage, daily intake of alcohol before treatment) - direct logistic regression was performed to analyze these factors' influence on treatment retention after controlling for medication groups and AA attendance.
RESULTS: Increasing age, participation in Alcoholics Anonymous groups, and beer preference among drinkers were independently associated with higher treatment retention. Conversely, higher scores for depression increased dropout rates.
CONCLUSION: Health services should identify the treatment practices and therapists that improve retention. Information about patients' characteristics linked to dropouts should be studied to render treatment programs more responsive and attractive, combining pharmacological agents with more intensive and diversified psychosocial interventions.

Descriptors: Pharmacological Trials; Craving; Alcoholics Anonymous Groups; Psychosocial Interventions.

9 - A reminiscence program intervention to improve the quality of life of long-term care residents with Alzheimer's disease. A randomized controlled trial
Daniel Jorge Luis Serrani Azcurra
Pages: 422 - 433

OBJECTIVE: A single-blinded, parallel-groups (intervention, active and passive control groups) randomized controlled trial (RCT) was chosen to investigate whether a specific reminiscence program is associated with higher levels of quality of life in nursing home residents with dementia.
METHODS: The intervention used a life-story approach, while the control groups participated in casual discussions. The Social Engagement Scale (SES) and Self Reported Quality of Life Scale (SRQoL) were used as the outcome measures, which were examined at baseline (T0), 12 weeks (T1), and six months (T2) after the intervention. The final sample had 135 subjects (active control group = 45; passive control group = 45; intervention group = 45).
RESULTS: The Wilcoxon test showed significant differences in the intervention group between T2 and T0, and between T1 and T0 in the SES, and there were significant differences between T0 and T1 (intervention effect size = 0.267) and T1 and T2 (intervention effect size = 0.450) in the SRQoL. The univariate logistic regression scores showed that predictors of change in the SRQoL were associated with fewer baseline anxiety symptoms and lower depression scores.
CONCLUSIONS: The intervention led to significant differences between the three groups over time, showing a significant improvement in the quality of life and engagement of the residents in the intervention group.

Descriptors: Dementia; Reminiscence; Life-Story Book; Randomized Controlled Trial; Nursing Home Care.

10 - Setting priorities for mental health research in Brazil
Guilherme Gregório, Mark Tomlinson, Jerônimo Gerolin, Christian Kieling, Hugo Cogo Moreira, Denise Razzouk, Jair de Jesus Mari
Pages: 434 - 439

BACKGROUND: The main aim of this study is to review the agenda for research priorities of mental health in Brazil. METHODOLOGY: The first step was to gather 28 experts (22 researchers, five policy makers, and the coordinator) representing all mental health fields from different geographical areas of the country. Participants were asked to list what they considered to be the most relevant mental health research questions for the country to address in the next 10 years. Seventeen participants answered this question; after redundancies were excluded, a total of 110 responses were collected. As the second step, participants were asked to rank which questions were the 35 most significant. The final step was to score 15 items for each of the 35 selected questions to determine whether it would be a) answerable, b) effective, c) deliverable, d) equitable, and e) effective at reducing the burden of mental health. The ten highest ranked questions were then selected. RESULTS: There were four questions addressing primary care with respect to a) the effectiveness of interventions, b) "matrix support", c) comparisons of different models of stepped care, and d) interventions to enhance identification and treatment of common mental disorders at the Family Health Program. The other questions were related to the evaluation of mental health services for adults and children/adolescents to clarify barriers to treatment in primary care, drug addiction, and severe mental disorders; to investigate the cost-benefit relationship of anti-psychotics; to design interventions to decrease alcohol consumption; and to apply new technologies (telemedicine) for education and supervision of non-specialists. CONCLUSION: This priority-setting research exercise highlighted a need for implementing investments at the primarycare level, particularly in the family health program; the urgent need to evaluate services; and policies to improve equity by increasing accessibility to services and testing interventions to reduce barriers for seeking mental health treatment.

Descriptors: Mental Health Services; Health Priorities; Health Priorities Agenda; Health Research Agenda; Health Care Rationing.

11 - Homozygosity for the APOE E4 allele is solely associated with lower cognitive performance in Brazilian communitydwelling older adults - The Bambuí Study
Sandra Regina Quintino-Santos; Maria Fernanda Lima-Costa; Elizabeth Uchoa; Josélia Oliveira de Araujo Firmo; Emílio Hideyuki Moriguchi; Érico de Castro-Costa
Pages: 440 - 445

OBJECTIVE: To investigate if APOE E4 allelic status is associated with the cognitive functioning of elderly individuals. Methods: Participants (n = 1,408) from the Bambuí Cohort Study of Aging were selected based on the results from both variables (APOE genotype and MMSE score). Gender, age, education, marital status, skin color, GHQ score and biological measures were used as confounding factors for adjusting the logistic regression.
RESULTS: The population was in Hardy-Weinberg equilibrium, and the APOE E4 allele frequency was 13.4%. APOE E4 allele homozygosity conferred a superior odds ratio (OR) for cognitive impairment (OR = 3.1) compared to E4 allele heterozygosity (OR = 0.99) even when adjusted for age, sex, education, marital status, skin color, triglycerides, HDL, systolic pressure, and GHQ (OR = 2.9). No differences were observed between the other covariates.
CONCLUSIONS: The APOE E4 allele was observed to have a dramatic effect on cognitive impairment, especially in homozygotes, which comprised approximately 2% of the population.

Descriptors: Cognitive Performance; Apolipoprotein E; MMSE; Elderly.

12 - Antenatal depression strongly predicts postnatal depression in primary health care
Alexandre Faisal-Cury; Paulo Rossi Menezes
Pages: 446 - 450

OBJECTIVE:To estimate the association between antenatal and postnatal depression and to examine the role of socioeconomic conditions in the risk of postnatal depression.
METHODS: A prospective cohort study, conducted between May 2005 and January 2006, with 831 pregnant women recruited from primary care clinics in the public sector in the city of São Paulo, Brazil. The presence of antenatal and postnatal depression was measured with the Self Report Questionnaire (SRQ-20). Sociodemographic and socioeconomic characteristics and obstetric information were obtained through a questionnaire. Crude and adjusted risk ratios (RR), with 95% CI, were calculated using a Poisson regression.
RESULTS: The prevalence of postnatal depressive symptoms was 31.2% (95%CI: 27.8-34.8%). Among the 219 mothers who had depressive symptoms, nearly 50% had already shown depressive symptoms during pregnancy. Women who had antenatal depression were 2.4 times more likely to present with postnatal depression than were women who did not have such symptoms during pregnancy. In the multivariate analysis, higher scores for assets (RR: 0.76, 95% CI 0.61-0.96), higher education (RR: 0.75 95%CI 0.59-0.96), daily contact with neighbors (RR: 0.68, 95%CI 0.51-0.90) and antenatal depression (RR: 2.44, 95%CI 1.93-3.08) remained independently associated with postnatal depression.
CONCLUSION: Antenatal and postnatal depression are highly prevalent in the primary care setting.

Descriptors: Antenatal Depression; Postnatal Depression; Risk Factors; SRQ-20.

13 - A case-control association study between Obsessive-Compulsive Disorder (OCD) and the MCP-1 -2518G/A polymorphism in a Chinese sample
Xinhua Zhang; Yingying Yin; Shiguo Liu; Xu Ma
Pages: 451 - 453

OBJECTIVE:To investigate the association between Obsessive-Compulsive Disorder (OCD) and a functional polymorphism of MCP-1 in the Chinese Han population.
METHOD: We genotyped and performed a case-control association analysis of the MCP-1 -2518G/A polymorphism in 200 OCD patients and 294 healthy control subjects.
RESULTS: There was no significant difference in MCP-1 -2518G/A genotypic and allelic frequencies between OCD cases and controls (χ2 = 1.123, df = 2, P = 0.57 by genotype; χ2 = 0.802, df = 1, P = 0.37 by allele).
CONCLUSION: Our results indicated that MCP-1 -2518G/A may not play a major role in the genetic predisposition of the Chinese Han population to OCD. However, further studies using a larger number of subjects are required to obtain a clear conclusion.

Descriptors: MCP-1 -2518G/A Polymorphism; OCD; Cytokines; Association Analysis

14 - Psychiatric comorbidities in temporal lobe epilepsy: Possible relationships between psychotic disorders and involvement of limbic circuits
Ludmyla Kandratavicius; Cleiton Lopes-Aguiar; Lézio Soares Bueno-Júnior; Rodrigo Neves Romcy-Pereira; Jaime Eduardo Cecilio Hallak; João Pereira Leite
Pages: 454 - 466

OBJECTIVE:Mounting evidence suggests that the limbic system is pathologically involved in cases of psychiatric comorbidities in temporal lobe epilepsy (TLE) patients. Our objective was to develop a conceptual framework describing how neuropathological and connectivity changes might contribute to the development of psychosis and to the potential neurobiological mechanisms that cause schizophrenia-like psychosis in TLE patients.
METHODS: In this review, clinical and neuropathological findings, especially brain circuitry of the limbic system, were examined together to enhance our understanding of the association between TLE and psychosis. Finally, the importance of animal models in epilepsy and psychiatric disorders was discussed.
CONCLUSION: TLE and psychiatric symptoms coexist more frequently than chance would predict. Damage and deregulation among critical anatomical regions, such as the hippocampus, amygdala, thalamus, and the temporal, frontal and cingulate cortices, might predispose TLE brains to psychosis. Studies of the effects of kindling and injection of neuroactive substances on behavior and electrophysiological patterns may offer a model of how limbic seizures in humans increase the vulnerability of TLE patients to psychiatric symptoms.

Descriptors: Temporal Lobe Epilepsy; Psychosis; Psychiatric Comorbidities; Neuropathology; Limbic Circuits.

15 - Bipolar disorder and Premenstrual Syndrome or Premenstrual Dysphoric Disorder comorbidity: a systematic review
Patricia Carvalho Cirillo; Roberta Benitez Freitas Passos; Mario Cesar do Nascimento Bevilaqua; Jose Ramón Rodriguez Arras López; Antônio Egidio Nardi
Pages: 467 - 479

OBJECTIVE: This article aims to review the comorbidity of premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD) and bipolar disorder (BD), identify variables requiring further investigation and to remind physicians that special care is required for diagnosis and therapy.
METHOD: A systematic review of articles published from 1987 to February 2012 was conducted in the Medline database with the following terms: (premenstrual syndrome OR premenstrual dysphoric disorder OR premenstrual) AND (bipolar OR mania OR manic). Seventeen articles were analyzed.
RESULTS: PMS and PMDD were most often comorbid among BD-II patients and vice versa. Moreover, patients with PMS or PMDD also have an increased risk of having BD-I. In addition, bipolar women susceptible to hormonal changes exhibit more severe symptoms, more frequent relapses and a worse therapeutic response.
CONCLUSION: Future investigations should attempt to stabilize hormonal levels through the continuous use of contraceptives to target a reduction in symptom severity. In addition, psychiatrists should note menstrual period dates and compare symptom intensity between the luteal and follicular phases. Finally, PMS and PMDD patients should be studied separately.

Descriptors: Bipolar Disorder; Estrogens; Premenstrual Syndrome; Progesterone; Serotonin.

16 - Impact of childhood stress on psychopathology
Elisa Brietzke; Márcia Kauer Sant'anna; Andréa Jackowski; Rodrigo Grassi-Oliveira; Joanna Bucker; André Zugman; Rodrigo Barbachan Mansur; Rodrigo Affonseca Bressan
Pages: 480 - 488

OBJECTIVE: Advances in our knowledge of mental disorder (MD) genetics have contributed to a better understanding of their pathophysiology. Nonetheless, several questions and doubts persist. Recent studies have focused on environmental influences in the development of MDs, and the advent of neuroscientific methodologies has provided new perspectives. Early life events, such as childhood stress, may affect neurodevelopment through mechanisms such as gene-environment interactions and epigenetic regulation, thus leading to diseases in adulthood. The aim of this paper is to review the evidence regarding the role of the environment, particularly childhood stress, in the pathophysiology of MD.
METHODOLOGY: We reviewed articles that evaluated environmental influences, with a particular focus on childhood trauma, brain morphology, cognitive functions, and the development of psychopathology and MD.
RESULTS AND CONCLUSION: MRI studies have shown that exposure to trauma at an early age can result in several neurostructural changes, such as the reduction of the hippocampus and corpus callosum. Cognitive performance and functioning are also altered in this population. Finally, childhood stress is related to an increased risk of developing MD such as depression, bipolar disorder, schizophrenia and substance abuse. We conclude that there is robust evidence of the role of the environment, specifically adverse childhood experiences, in various aspects of MD.

Descriptors: Childhood Maltreatment; Trauma; Early Life Stress; Post-Traumatic Stress Disorder; Cognition; Bipolar Disorder.

17 - Suicide among the indigenous people in Brazil: a hidden public health issue
Maximiliano Loiola Ponte de Souza; Jesem Douglas Yamall Orellana
Pages: 489 - 492


18 - School referrals of children and adolescents to CAPSi - the burden of incorrect referrals
Daniela Bordini; Ary Gadelha; Cristiane Silvestre Paula; Rodrigo Affonseca Bressan
Pages: 493 - 496


19 - Imipramine-induced dystonia in a child: a case report
Filipe Augusto Cursino Freitas; Arthur Kummer; Antônio Lúcio Teixeira
Pages: 497 - 500


20 - Hypothyroidism and severe neuropsychiatric symptoms: a rapid response to levothyroxine
Eduardo Trachtenberg; Ives Cavalcante Passos; Werner Weiss Kleina; Da Rocha de Neusa Sica; Marcelo Pio de Almeida Fleck
Pages: 501 - 504


21 - Depersonalization and derealization syndrome: report on a case study and pharmacological management
Ana Salgado; Leonardo Oliveira; Mauricio Sierra-Siegert; João Vinicius Salgado
Pages: 505 - 508


22 - Early joint attention deficits in autism: evidence from a retrospective case
Caroline Greiner de Magalhães; Poliana Gonçalves Barbosa; Camila Soares de Abreu; Cláudia Cardoso-Martins
Pages: 509 - 512


23 - ADHD is undertreated in Brazil
Paulo Mattos; Luis Augusto Rohde; Guilherme V. Polanczyk
Pages: 513 - 516


24 - George Harrison's inner light
Guilherme Nogueira M de Oliveira; João Vinícius Salgado; Izabela Guimarães Barbosa; Antônio Lúcio Teixeira
Pages: 517 - 518


26 - Schizophrenia: Progress in multidisciplinary treatment
Emerson Arcoverde Nunes
Pages: 521 - 522