Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2017: 2.093
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Current issue 2, Volume 35 - Apr/May/Jun/2013


1 - The quest for better diagnosis: DSM-5 or RDoC?
Antonio Egidio Nardi; Flavio Kapczinski; João Quevedo; Jaime E.C. Hallak; Rafael Freire; Marco Aurélio Romano-Silva
Pages: 109 - 110


3 - Objectivity and subjectivity in forensic psychiatry
Elias Abdalla-Filho
Pages: 113 - 114


4 - Family burden related to mental and physical disorders in the world: results from the WHO World Mental Health (WMH) surveys
Maria Carmen Viana; Michael J. Gruber; Victoria Shahly; Ali Alhamzawi; Jordi Alonso; Laura H. Andrade; Matthias C. Angermeyer; Corina Benjet; Ronny Bruffaerts; Jose Miguel Caldas-de-Almeida; Giovanni de Girolamo; Peter de Jonge; Finola Ferry; Silvia Florescu; Oye Gureje; Josep Maria Haro; Hristo Hinkov; Chiyi Hu; Elie G. Karam; Jean-Pierre Lépine; Daphna Levinson; Jose Posada-Villa; Nancy A. Sampson; Ronald C. Kessler
Pages: 115 - 125

OBJECTIVE: To assess prevalence and correlates of family caregiver burdens associated with mental and physical conditions worldwide.
METHODS: Cross-sectional community surveys asked 43,732 adults residing in 19 countries of the WHO World Mental Health (WMH) Surveys about chronic physical and mental health conditions of first-degree relatives and associated objective (time, financial) and subjective (distress, embarrassment) burdens. Magnitudes and associations of burden are examined by kinship status and family health problem; population-level estimates are provided.
RESULTS: Among the 18.9-40.3% of respondents in high, upper-middle, and low/lower-middle income countries with first-degree relatives having serious health problems, 39.0-39.6% reported burden. Among those, 22.9-31.1% devoted time, 10.6-18.8% had financial burden, 23.3-27.1% reported psychological distress, and 6.0-17.2% embarrassment. Mean caregiving hours/week was 12.9-16.5 (83.7-147.9 hours/week/100 people aged 18+). Mean financial burden was 15.1% of median family income in high, 32.2% in upper-middle, and 44.1% in low/lower-middle income countries. A higher burden was reported by women than men, and for care of parents, spouses, and children than siblings.
CONCLUSIONS: The uncompensated labor of family caregivers is associated with substantial objective and subjective burden worldwide. Given the growing public health importance of the family caregiving system, it is vital to develop effective interventions that support family caregivers.

Descriptors: Caregiver burden; family caregiver; cross-national; population-based; epidemiology; mental health

5 - Cardiovascular risk factors in outpatients with bipolar disorder: a report from the Brazilian Research Network in Bipolar Disorder
Fabiano A. Gomes; Karla M. Almeida; Pedro V. Magalhães; Sheila C. Caetano; Márcia Kauer Sant'Anna; Beny Lafer; Flávio Kapczinski
Pages: 126 - 130

OBJECTIVE: Bipolar disorder (BD) is associated with significant morbidity and mortality due to comorbid general medical conditions, particularly cardiovascular disease. This study is the first report of the Brazilian Research Network in Bipolar Disorder (BRN-BD) that aims to evaluate the prevalence and clinical correlates of cardiovascular risk factors among Brazilian patients with BD.
METHODS: A cross-sectional study of 159 patients with DSM-IV BD, 18 years or older, consecutively recruited from the Bipolar Research Program (PROMAN) in São Paulo and the Bipolar Disorder Program (PROTAHBI) in Porto Alegre. Clinical, demographic, anthropometric, and metabolic variables were systematically assessed.
RESULTS: High rates of smoking (27%), physical inactivity (64.9%), alcohol use disorders (20.8%), elevated fasting glucose (26.4%), diabetes (13.2%), hypertension (38.4%), hypertriglyceridemia (25.8%), low HDL-cholesterol (27.7%), general (38.4%) and abdominal obesity (59.1%) were found in the sample. Male patients were more likely to have alcohol use disorders, diabetes, and hypertriglyceridemia, whereas female patients showed higher prevalence of abdominal obesity. Variables such as medication use pattern, alcohol use disorder, and physical activity were associated with selected cardiovascular risk factors in the multivariable analysis.
CONCLUSION: This report of the BRN-BD provides new data regarding prevalence rates and associated cardiovascular risk factors in Brazilian outpatients with BD. There is a need for increasing both awareness and recognition about metabolic and cardiovascular diseases in this patient population.

Descriptors: Bipolar disorder; cardiovascular risk factors; comorbidity

6 - Metabolic syndrome prevalence in different affective temperament profiles in bipolar-I disorder
Kursat Altinbas; Sinan Guloksuz; E. Timucin Oral
Pages: 131 - 135

OBJECTIVE: Temperament originates in the brain structure, and individual differences are attributable to neural and physiological function differences. It has been suggested that temperament is associated with metabolic syndrome (MetS) markers, which may be partly mediated by lifestyle and socioeconomic status. Therefore, we aim to compare MetS prevalence between different affective temperamental profiles for each season in bipolar patients.
METHODS: Twenty-six bipolar type-I patients of a specialized outpatient mood disorder unit were evaluated for MetS according to new definition proposed by the International Diabetes Federation in the four seasons of a year. Temperament was assessed using the Temperament Evaluation of Memphis, Pisa, Paris and San Diego - autoquestionnaire version (TEMPS-A).
RESULTS: The proportions of MetS were 19.2, 23.1, 34.6, and 38.5% in the summer, fall, spring, and winter, respectively. Only depressive temperament scores were higher (p = 0.002) during the winter in patients with MetS.
CONCLUSION: These data suggest that depressive temperament profiles may predispose an individual to the development of MetS in the winter.

Descriptors: Bipolar disorder; temperament; metabolic syndrome

7 - Treatment of anxiety disorders by psychiatrists from the American Psychiatric Practice Research Network
Katherine Sorsdahl; Carlos Blanco; Donald S. Rae; Harold Pincus; William E. Narrow; Sharain Suliman; Dan J. Stein
Pages: 136 - 141

OBJECTIVE: Anxiety disorders are highly prevalent in the United States, and if untreated, result in a number of negative outcomes. This study aimed to investigate psychiatrists' current treatment practices for patients with anxiety disorders in the United States.
METHODS: Psychiatrist-reported data from the 1997 and 1999 American Psychiatric Institute for Research and Education Practice Research Network (PRN) Study of Psychiatric Patients and Treatments (SPPT) were examined, focusing on patients diagnosed with anxiety disorders. Information related to diagnostic and clinical features and treatments provided were obtained.
RESULTS: Anxiety disorders remain underdiagnosed and undertreated, since only 11.4% of the sample received a principal diagnosis of an anxiety disorder in a real world setting. Posttraumatic stress disorder was associated with particularly high comorbidity and disability, and social anxiety disorder was relatively rarely diagnosed and treated. Although combined pharmacotherapy and psychotherapy was commonly used to treat anxiety disorders, anxiolytics were more commonly prescribed than selective serotonin reuptake inhibitors (SSRIs).
CONCLUSIONS: These data provide a picture of diagnosis and practice patterns across a range of psychiatric settings and suggest that anxiety disorders, despite being among the most prevalent of psychiatric disorders remain underdiagnosed and undertreated particularly in respect of the use of psychotherapeutic interventions.

Descriptors: Anxiety disorders; treatment setting; treatment characteristics

8 - Higher prevalence of major depressive symptoms in Brazilians aged 14 and older
Cassiano L.S. Coelho; José Alexandre S. Crippa; Jair L.F. Santos; Ilana Pinsky; Marcos Zaleski; Raul Caetano; Ronaldo Laranjeira
Pages: 142 - 149

OBJECTIVE: Depression is a highly prevalent condition and is considered a major public health issue. The aim of the present study was to estimate the prevalence of depressive symptoms in the Brazilian population and establish their sociodemographic correlates.
METHOD: A cross-sectional study was conducted between November 2005 and April 2006. Data were collected in face-to-face interviews using a standardized questionnaire. The sample consisted of 3,007 interviews with individuals aged 14 years and older and followed a probabilistic design covering the Brazilian national territory. Depressive symptoms were assessed according to the Center for Epidemiologic Studies Depression Scale.
RESULTS: The observed prevalence of depressive symptoms was 28.3% (13% mild/moderate; 15.3% major/severe; p < 0.01). Increased depressive symptom rates were associated with being a female, being 45 years of age and older, having lower educational attainment, being single, having family income of up to 2.5 times minimum wage, and living in the northern region of Brazil (p < 0.05).
CONCLUSIONS: The prevalence of depressive symptoms in Brazil is high, with major depressive symptoms being the most frequent form of this symptomatology. Considering the biopsychosocial model of mental disorders, this survey points to the involvement of psychosocial factors in the prevalence of depressive symptoms in Brazil.

Descriptors: Mood disorders; unipolar; community mental health; epidemiology; statistics; other research areas

9 - Risk behaviors for eating disorder in adolescents and adults with type 1 diabetes
Sonia Tucunduva Philippi; Milena Gonçalves Lima Cardoso; Priscila Koritar; Marle Alvarenga
Pages: 150 - 156

OBJECTIVE: To evaluate the frequency of risk behaviors for eating disorder (ED) in patients with type 1 diabetes (T1D) and their association with gender, nutritional status, variables related to T1D, and body satisfaction.
METHOD: 189 individuals with T1D (12-56 years old) answered the Bulimic Investigation Test (BITE), the Eating Attitude Test (EAT), the Binge Eating Scale (BES), Stunkard's Figure Rating Scale, and questions regarding control of T1D. Association between ED risk behaviors and the selected variables was assessed with the chi-square test and Student's t-test; factors that influenced the risk of ED were identified by means of logistic regression.
RESULTS: Of the patients with T1D, 58.7% were at risk of ED (45, 40, and 16% according to the EAT, BITE and BES, respectively). There were significant differences between groups with and without risk for ED related to BMI (p = 0.009), gender (p = 0.001), insulin omission (p = 0.003), use of the carbohydrate counting method (p = 0.019), and body dissatisfaction (p = 0.001). The risk of ED was nine times higher in patients who reduced or omitted insulin (p = 0.036).
CONCLUSIONS: Patients with T1D demonstrated a high frequency of body dissatisfaction and ED risk behaviors; the omission or reduction of insulin was an important risk factor.

Descriptors: Eating disorders; nutrition; other disorders; other specialties; women

10 - Homocysteine and other markers of cardiovascular risk during a manic episode in patients with bipolar disorder
Fábria Chiarani; Juliana Fernandes Tramontina; Keila Maria Ceresér; Maurício Kunz; Leonardo Paim; Carmen Regla Vargas; Angela Sitta; Sérgio Pinto Machado; Angela Terezinha de Souza Wyse; Flávio Pereira Kapczinski
Pages: 157 - 160

OBJECTIVE: To evaluate serum levels of different biomarkers associated with cardiovascular disease in patients with bipolar disorder (BD). Patients were prospectively evaluated in two separate instances: during acute mania and after remission of manic symptoms. All measurements were compared with those of healthy controls.
METHODS: The study included 30 patients with BD and 30 healthy controls, matched for gender and age. Biochemical parameters evaluated included homocysteine (Hcy), folic acid, vitamin B12, ferritin, creatine kinase (CK) and C-reactive protein (CRP).
RESULTS: Hcy levels were significantly higher in the BD patients, both during mania and after achieving euthymia. When Hcy was adjusted for body mass index, there was no significant difference between patients and controls. Ferritin was the only marker that showed a significant decrease during mania when compared to both euthymic patients and controls. There were no significant differences for folate, vitamin B12, CK and CRP.
CONCLUSIONS: These findings do not show an association between alterations of markers of cardiovascular risk during manic episodes. Further studies are necessary to determine factors and mechanisms associated with cardiovascular risk in patients with BD.

Descriptors: Homocysteine; ferritin; bipolar disorder; cardiovascular disease

11 - Mexican immigration to the U.S., the occurrence of violence and the impact of mental disorders
Guilherme Borges; Claudia Rafful; Daniel J. Tancredi; Naomi Saito; Sergio Aguilar-Gaxiola; Maria-Elena Medina-Mora; Joshua Breslau
Pages: 161 - 168

OBJECTIVE: To study immigration, U.S. nativity, and return migration as risk factors for violence among people of Mexican origin in the U.S. and Mexico.
METHODS: Cross-sectional surveys in the United States (2001-2003; n=1,213) and Mexico (20012002; n=2,362). Discrete time survival models were used. The reference group was Mexicans living in Mexico without migrant experience or a migrant relative.
RESULTS: Mexican immigrants in the U.S. have lower risk for any violence (hazard ratio [HR] = 0.5, 95% confidence interval [95%CI] 0.4-0.7). U.S.-born Mexican-Americans were at higher risk for violence victimization of a sexual nature (for sexual assault, HR = 2.5, 95%CI 1.7-3.7). Return migrants were at increased risk for being kidnapped or held hostage (HR = 2.8, 95%CI 1.1-7.1). Compared to those without a mental disorder, those with a mental disorder were more likely to suffer any violence (HR = 2.3, 95%CI 1.9-2.7), regardless of the migrant experience.
CONCLUSIONS: The impact of immigration on the occurrence of violence is more complex than usually believed. Return migrants are more likely to suffer violence such as being held hostage or beaten by someone other than a partner.

Descriptors: Immigration; Mexican-American; survey; mental disorder; violence; Hispanic American

12 - Structural validity and reliability of the Positive and Negative Affect Schedule (PANAS): Evidence from a large Brazilian community sample
Hudson W. de Carvalho; Sérgio B. Andreoli; Diogo R. Lara; Christopher J. Patrick; Maria Inês Quintana; Rodrigo A. Bressan; Marcelo F. de Melo; Jair de J. Mari; Miguel R. Jorge
Pages: 169 - 172

OBJECTIVE: Positive and negative affect are the two psychobiological-dispositional dimensions reflecting proneness to positive and negative activation that influence the extent to which individuals experience life events as joyful or as distressful. The Positive and Negative Affect Schedule (PANAS) is a structured questionnaire that provides independent indexes of positive and negative affect. This study aimed to validate a Brazilian interview-version of the PANAS by means of factor and internal consistency analysis.
METHODS: A representative community sample of 3,728 individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil, voluntarily completed the PANAS. Exploratory structural equation model analysis was based on maximum likelihood estimation and reliability was calculated via Cronbach's alpha coefficient.
RESULTS: Our results provide support for the hypothesis that the PANAS reliably measures two distinct dimensions of positive and negative affect.
CONCLUSION: The structure and reliability of the Brazilian version of the PANAS are consistent with those of its original version. Taken together, these results attest the validity of the Brazilian adaptation of the instrument.

Descriptors: Emotion; epidemiology; structural equation modeling; psychometrics; Positive and Negative Affect Schedule

13 - New frontiers in the study of memory mechanisms
Cristiane R.G. Furini; Jociane C. Myskiw; Fernando Benetti; Ivan Izquierdo
Pages: 173 - 177

We review recent work on three major lines of memory research: a) the possible role of the protein kinase M-zeta (PKMzeta) in memory persistence; b) the processes of "synaptic tagging and capture" in memory formation; c) the modulation of extinction learning, widely used in the psychotherapy of fear memories under the name of "exposure therapy". PKMzeta is a form of protein kinase C (PKC) that apparently remains stimulated for months after the consolidation of a given memory. Synaptic tagging is a mechanism whereby the weak activation of one synapse can tag it with a protein so other synapses in the same cell can reactivate it by producing other proteins that bind to the tag. Extinction, once mistakenly labeled as a form of forgetting, is by itself a form of learning; through it animals can learn to inhibit a response. We now know it can be modulated by neurotransmitters or by synaptic tagging, which should enable better control of its clinical use.

Descriptors: Memory; persistence; consolidation; synaptic tagging; extinction

14 - Mild cognitive impairment (part 1): clinical characteristics and predictors of dementia
Orestes V. Forlenza; Breno S. Diniz; Florindo Stella; Antonio L. Teixeira; Wagner F. Gattaz
Pages: 178 - 185

OBJECTIVE: To critically review and evaluate existing knowledge on the conceptual limits and clinical usefulness of the diagnosis of mild cognitive impairment (MCI) and the neuropsychological assessment and short-and long-term prognosis thereof.
METHODS: We conducted a systematic search of the PubMed and Web of Science electronic databases, limited to articles published in English between 1999 and 2012. Based on the search terms mild cognitive impairment or MCI and epidemiology or diagnosis, we retrieved 1,698 articles, of which 248 were critically eligible (cross-sectional and longitudinal studies); the abstracts of the remaining 1,450 articles were also reviewed.
RESULTS: A critical review on the MCI construct is provided, including conceptual and diagnostic aspects; epidemiological relevance; clinical assessment; prognosis; and outcome. The distinct definitions of cognitive impairment, MCI included, yield clinically heterogeneous groups of individuals. Those who will eventually progress to dementia may present with symptoms consistent with the definition of MCI; conversely, individuals with MCI may remain stable or return to normal cognitive function.
CONCLUSION: On clinical grounds, the cross-sectional diagnosis of MCI has limited prognostic relevance. The characterization of persistent and/or progressive cognitive deficits over time is a better approach for identification of cases at the pre-dementia stages, particularly if these cognitive abnormalities are consistent with the natural history of incipient Alzheimer's disease.

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

15 - Economic evaluation in the field of mental health: conceptual basis
Ana Flávia Barros da Silva Lima; Luciane Nascimento Cruz; Carisi Anne Polanczyk; Carlos Renato Moreira Maia
Pages: 186 - 192

OBJECTIVE: Technological advances in medicine have given rise to a dilemma concerning the use of new health technologies in a context of limited financial resources. In the field of psychiatry, health economic evaluation is a recent method that can assist in choosing interventions with different cost and/or effectiveness for specific populations or conditions. This article introduces clinicians to the fundamental concepts required for critical assessment of health economic evaluations.
METHODS: The authors conducted a review with systematic methods to assess the essential theoretical framework of health economic evaluation and mental health in Brazil through textbooks and studies indexed in the PubMed, Cochrane Central, LILACS, NHS CRD, and REBRATS databases. A total of 334 studies were found using the specified terms (MeSH - Mental Health AND Economic, Medical) and filters (Brazil AND Humans); however, only five Brazilian economic evaluations were found.
RESULTS AND CONCLUSIONS: Economic evaluation studies are growing exponentially in the medical literature. Publications focusing on health economics as applied to psychiatry are increasingly common, but Brazilian data are still very incipient. In a country where financial resources are so scarce, economic analyses are necessary to ensure better use of public resources and wider population access to effective health technologies.

Descriptors: Health technology assessment; health economics; cost-effectiveness; epidemiology

16 - Cognitive functions in patients with panic disorder: a literature review
Mariana Rodrigues Poubel Alves; Valeska Martinho Pereira; Sérgio Machado; Antonio Egidio Nardi; Adriana Cardoso de Oliveira e Silva
Pages: 193 - 200

OBJECTIVE: To conduct a review of the literature on the possible neuropsychological deficits present in patients with panic disorder.
METHODS: We performed a systematic review and search of the PubMed, ISI and PsycInfo scientific databases, with no time limits, using the following key words: cognitive, function, panic, and disorder. Of the 971 articles found, 25 were selected and 17 were included in this review. The inclusion criterion was at least one neuropsychological assessment task in patients with panic disorder.
RESULTS: The number of publications has grown gradually, especially those assessing executive functions, corresponding to the neurobiological model most widely accepted. Of all the functions evaluated, these patients had lower performance in memory tasks and higher performance in affective processing tasks related to the disorder. However, these data require further investigation due to the high rate of comorbidities, the small sample sizes of the included studies and little standardization of instruments used.
CONCLUSION: The results showed a greater occurrence of deficits in memory and enhanced affective processing related to panic disorder.

Descriptors: Panic disorder; cognitive function; memory; affective processing; executive functions

17 - Depressive morbidity among elderly individuals who are hospitalized, reside at long-term care facilities, and are under outpatient care in Brazil: a meta-analysis
Luís Fernando S. Castro-de-Araújo; Ricardo Barcelos-Ferreira; Camila Bertini Martins; Cássio M.C. Bottino
Pages: 201 - 207

OBJECTIVES: i) To investigate studies published between 1991 and 2010 on the prevalence of depressive morbidity (major depressive disorder [MDD], dysthymia and clinically significant depressive symptoms [CSDS]) among elderly Brazilians assisted at healthcare facilities; ii) to establish the prevalence of depression and identify its related factors; and iii) to conduct a meta-analysis to assess the prevalence of depressive syndrome among elderly individuals assisted or hospitalized at healthcare facilities.
METHODS: Studies were selected from articles dated between January 1991 and June 2010 and extracted from the MEDLINE, LILACS, and SciELO databases.
RESULTS: The final analysis consisted of 15 studies, distributed as follows: i) four sampled hospitalized patients, totaling 299 individuals, and found a prevalence of CSDS varying between 20 and 56%; ii) four sampled outpatients, totaling 1,454 individuals; the prevalence of CSDS varied between 11 and 65%, and the prevalence of MDD varied between 23 and 42%; and iii) seven sampled elderly individuals residing in long-term care facilities (LTCF), totaling 839 individuals, and the prevalence of CSDS varied between 11 and 65%.
CONCLUSION: The present review indicated a higher prevalence of both MDD and CSDS among elderly Brazilians assisted at healthcare facilities.

Descriptors: Geriatric psychiatry; mood disorders - unipolar; chronic psychiatric illness; inpatient psychiatry; epidemiology

18 - Did the "father of aviation" have his wings clipped by depression?
Régis Eric Maia Barros
Pages: 208 - 209


19 - Seasonal and temperamental contributions in patients with bipolar disorder and metabolic syndrome
Roger S. McIntyre
Pages: 210 - 210


20 - rTMS as an add-on treatment for resistant obsessive-compulsive symptoms in patients with schizophrenia: report of three cases
Vauto Alves Mendes-Filho; Paulo Belmonte-de-Abreu; Mariana Pedrini; Carolina Tosetto Cachoeira; Maria Inês Rodrigues Lobato
Pages: 210 - 211


21 - Cotard's syndrome and major depression with psychotic symptoms
Leonardo Machado; Antonio Peregrino; Suzana Azoubel; Helena Cerqueira; Luiz Evandro de Lima Filho
Pages: 212 - 212


22 - The utility of intravenous clomipramine in a case of Cotard's syndrome
Rui Lopes; Isabel Costa; Rosário Curral; Manuel Esteves; António Roma-Torres
Pages: 212 - 213


23 - Corrigendum

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