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 1, Volume 38 - Jan/Feb/Mar/2016


1 - Neural correlates of hallucinations in bipolar disorder
Maila de C. Neves; Dante G. Duarte; Maicon R. Albuquerque; Rodrigo Nicolato; Fernando S. Neves; Fábio L. de Souza-Duran; Geraldo Busatto; Humberto Corrêa
Pages: 1 - 5

OBJECTIVE: Approximately one-half of all patients affected by bipolar disorder present with psychotic features on at least one occasion. Several studies have found that alterations in the activity of mesolimbic and prefrontal regions are related to aberrant salience in psychotic patients. The aim of the present study was to investigate the structural correlates of a history of hallucinations in a sample of euthymic patients with bipolar I disorder (BD-I).
METHODS: The sample consisted of 21 euthymic patients with BD-I and no comorbid axis I DSM-IV-TR disorders. Voxel based morphometry (VBM) was used to compare patients with and without a lifetime history of hallucinations. Preprocessing was performed using the Diffeomorphic Anatomical Registration through Exponentiated Lie Algebra (DARTEL) algorithm for VBM in SPM8. Images were processed using optimized VBM.
RESULTS: The main finding of the present study was a reduction in gray matter volume in the right posterior insular cortex of patients with BD-I and a lifetime history of hallucinations, as compared to subjects with the same diagnosis but no history of hallucinations.
CONCLUSIONS: This finding supports the presence of abnormalities in the salience network in BD patients with a lifetime history of hallucinations. These alterations may be associated with an aberrant assignment of salience to the elements of one's own experience, which could result in psychotic symptoms.

Descriptors: Bipolar disorder; hallucinations; salience network; voxel-based morphometry

2 - Association between duration of untreated bipolar disorder and clinical outcome: data from a Brazilian sample
Gustavo C. Medeiros; Sofia B. Senço; Beny Lafer; Karla M. Almeida
Pages: 6 - 10

OBJECTIVE: Bipolar disorder (BD) is often left untreated for long periods, and this delay in treatment correlates with unfavorable prognosis. The present study sought to assess the magnitude of duration of untreated bipolar disorder (DUB) in Brazil. We hypothesized that DUB would be longer in Brazil than in developed countries, and would be associated with poor clinical outcomes.
METHODS: One hundred and fifty-two psychiatric outpatients were evaluated for BD diagnosis, demographics, DUB, and clinical outcomes.
RESULTS: The mean age and mean DUB were, respectively, 38.9±10.8 and 10.4±9.8 years. An extended DUB was associated with early onset of BD (p < 0.001), depression as first mood episode (p = 0.04), and presence of BD in a first-degree relative (p = 0.012). Additionally, a longer DUB was associated with poorer clinical outcomes, such as elevated rates of rapid cycling (p = 0.004) and anxiety disorders (p = 0.016), as well as lower levels of current full remission (p = 0.021).
CONCLUSION: As DUB may be a modifiable variable, better medical education regarding mental health, more structured medical services, and population-wide psychoeducation might reduce the time between onset and proper management of BD, thus improving outcome.

Descriptors: Community mental health; mood disorders; bipolar disorder; outpatient psychiatry; chronic psychiatric illness

3 - Hair cortisol in drug-naïve first-episode individuals with psychosis
Elvis H. Andrade; Lucas B. Rizzo; Cristiano Noto; Vanessa K. Ota; Ary Gadelha; Ledo Daruy-Filho; Brazílio de C. Tasso; Rodrigo B. Mansur; Quirino Cordeiro; Síntia I. Belangero; Rodrigo A. Bressan; Rodrigo Grassi-Oliveira; Elisa Brietzke
Pages: 11 - 16

OBJECTIVES: To compare hair cortisol concentrations (HCC) in drug-naïve first-episode psychosis (FEP) patients and healthy controls and to investigate the correlations between HCC and psychopathology.
METHODS: Twenty-four drug-naïve FEP patients and 27 gender- and age-matched healthy control subjects were recruited. The Structured Clinical Interview for DSM-IV (SCID-1) was used to confirm/rule out diagnoses, and the Positive and Negative Symptoms Scale (PANSS) was used to assess symptom severity. Hair samples (2-3 cm long) obtained from the posterior vertex region of the scalp were processed in 1-cm segments considering a hair growth rate of 1 cm per month. The 1-cm segments were classified according to their proximity to the scalp: segment A was the closest to the scalp and referred to the month prior to inclusion in the study. Segments B and C referred to the 2nd and 3rd months prior to the time of evaluation respectively. Hair steroid extraction was performed using a known protocol.
RESULTS: Two-way analysis of covariance (ANCOVA) with gender and age as covariates revealed a group effect (F1.106 = 4.899, p = 0.029) on HCC. Between-segment differences correlated with total PANSS score and with PANSS General Psychopathology subscale and total score.
CONCLUSIONS: Our findings suggest that hypothalamic-pituitary-adrenal (HPA) axis, as assessed by long-term (3-month) cortisol concentration, is abnormal in the early stages of psychosis. The magnitude of changes in HCC over time prior to the FEP correlates to psychopathology. HPA axis abnormalities might begin prior to full-blown clinical presentation requiring hospital admission.

Descriptors: First-episode psychosis; schizophrenia; cortisol; stress

4 - Symmetry symptoms in obsessive-compulsive disorder: clinical and genetic correlates
Christine Lochner; Nathaniel McGregor; Sian Hemmings; Brian H. Harvey; Elsie Breet; Sonja Swanevelder; Dan J. Stein
Pages: 17 - 23

OBJECTIVE: In obsessive-compulsive disorder (OCD), symmetry-related symptoms may be important. Although clinical correlates of symmetry-related symptoms have been identified in OCD, few data exist on genetic associations. Animal studies indicate involvement of dopamine in symmetry-related behavior, suggesting this may be relevant to analogous symptoms in OCD. Alterations in dopamine may also reflect environmental influences. However, the association of symmetry-related symptomatology, early adversity, and polymorphisms in dopaminergic genes has not been investigated in OCD.
METHODS: Clinical information and polymorphisms in key dopaminergic genes were compared between OCD patients with primary symmetry symptoms and those without.
RESULTS: OCD patients with primary symmetry symptoms comprised 46.6% (n=210) of the sample (n=451), and were older (p < 0.01), had longer illness duration (p < 0.01), higher OCD severity scores (p = 0.01), and greater comorbidity (p < 0.01) than those without. In Caucasians (n=343), genotype frequency differed significantly between groups for ANKK1 rs1800497, with more OCD patients with symmetry symptoms being homozygous for the A2 (CC) genotype(χ2 = 7.296; p = 0.026).
CONCLUSION: Symmetry symptoms have some distinct clinical features and may represent a marker of severity in OCD. However, clinical associations, in combination with the association found with the ANKK1 rs1800497 A2 variant, suggest that primary symmetry symptoms may represent a distinctive clinical and psychobiological profile.

Descriptors: Obsessive-compulsive disorder; symptom subtype; trauma; genetics; dopamine

5 - Virtual reality exposure using three-dimensional images for the treatment of social phobia
Cristiane M. Gebara; Tito P. de Barros-Neto; Leticia Gertsenchtein; Francisco Lotufo-Neto
Pages: 24 - 29

OBJECTIVE: To test a potential treatment for social phobia, which provides exposure to phobia-inducing situations via computer-generated, three-dimensional images, using an open clinical trial design.
METHODS: Twenty-one patients with a DSM-IV diagnosis of social phobia took part in the trial. Treatment consisted of up to 12 sessions of exposure to relevant images, each session lasting 50 minutes.
RESULTS: Improvements in social anxiety were seen in all scales and instruments used, including at follow-up 6 months after the end of treatment. The average number of sessions was seven, as the participants habituated rapidly to the process. Only one participant dropped out.
CONCLUSION: This study provides evidence that exposure to computer-generated three-dimensional images is relatively inexpensive, leads to greater treatment adherence, and can reduce social anxiety. Further studies are needed to corroborate these findings.

Descriptors: Social phobia; cognitive behavioral therapy; virtual reality exposure; anxiety

6 - Cost-utility analysis of methylphenidate treatment for children and adolescents with ADHD in Brazil
Carlos R. Maia; Steffan F. Stella; Flavia Wagner; Thiago G. Pianca; Fernanda V. Krieger; Luciane N. Cruz; Guilherme V. Polanczyk; Luis A. Rohde; Carisi A. Polanczyk
Pages: 30 - 38

OBJECTIVE: To perform a cost-utility analysis on the treatment of attention deficit hyperactivity disorder (ADHD) with methylphenidate immediate-release (MPH-IR) in children and adolescents from Brazil.
METHOD: A Markov model was constructed to compare MPH-IR vs. no treatment. A 24-week naturalistic study was conducted to collect transition probabilities and utility data. Effectiveness was expressed as quality-adjusted life-years (QALY), and costs reported in 2014 international dollars (I$). The perspective was the Brazilian Unified Health System as payer, and the time horizon was 6 years.
RESULTS: Of 171 patients, 73 provided information at baseline, and 56 at week 24. Considering the MPH-IR monthly cost of I$ 38, the incremental cost-effectiveness ratio (ICER) of treatment was I$ 9,103/QALY for children and I$ 11,883/QALY for adolescents. In two-way sensitivity analysis, considering one Gross National Product per capita (I$ 11,530) as willingness-to-pay, a cost of no-treatment lower than I$ 45/month would render MPH-IR a cost-saving strategy.
DISCUSSION: MPH-IR treatment of children and adolescents is cost-effective for ADHD patients from the Brazilian public health system perspective. Both patients and the healthcare system might benefit from such a strategy.

Descriptors: Attention deficit hyperactivity disorder; cost-utility analysis; methylphenidate

7 - Co-occurrence of communication disorder and psychiatric disorders in maltreated children and adolescents: relationship with global functioning
Luciene Stivanin; Christian C. de Oliveira; Fernanda P. dos Santos; Bernardo dos Santos; Sandra Scivoletto
Pages: 39 - 45

OBJECTIVE: To study the co-occurrence of psychiatric disorders (PD) and communication disorders (CD) and their relationship with global functioning in maltreated children and adolescents.
METHODS: The sample comprised 143 maltreated children and adolescents (55.8% male). All underwent clinical communication and psychiatric evaluations, as well as global functioning assessment using the Children's Global Assessment Scale (C-GAS).
RESULTS: Four groups emerged from evaluation: Group 1 (n=7, 4.9%) did not exhibit any disorders; Group 2 (n=26, 18.2%) exhibited PD; Group 3 (n=34, 23.8%) exhibited CD; and Group 4 (n=76, 53.1%) exhibited both Pd and CD on evaluation. Significant differences in global functioning scores were found between G1 and G2, G1 and G4, G2 and G4, and G3 and G4, with the highest C-GAS scores found in G1 and the lowest in G4.
CONCLUSION: Rates of PD and CD are high in this maltreated population. The presence of PD has a major impact on C-GAS score, and the simultaneous presence of CD increases the already impaired function of PD. Demonstration of the additive effects of PD and CD on youth functioning suggests that professionals should be alert to the presence of both disorders to better act preventively and therapeutically in a high-risk population.

Descriptors: Attention-deficit hyperactivity disorder; stress; child psychiatry; language; violence/aggression

8 - Prevalence of behavior problems and associated factors in preschool children from the city of Salvador, state of Bahia, Brazil
Letícia M. dos Santos; Fernanda C. Queirós; Maurício L. Barreto; Darci N. dos Santos
Pages: 46 - 52

OBJECTIVE: To identify the prevalence of internalizing and externalizing behavior problems among preschoolers from the city of Salvador, state of Bahia, Brazil, and their associations with maternal mental health and family characteristics.
METHODS: This was a cross-sectional study of 349 children aged 49 to 72 months, randomly selected from 20,000 households representing the range of socioeconomic and environmental conditions in Salvador. In 1999, we assessed sociodemographic variables and family environment characteristics. In 2001, we used the Child Behavior Checklist to measure and describe the frequencies of behavior problems. We conducted bivariate and multivariate analysis to estimate associations between family and maternal factors and prevalence of behavior problems.
RESULTS: The overall prevalence of behavior problems was 23.5%. The prevalence of internalizing problems was 9.7%, and that of externalizing problems, 25.2%. Behavior problems were associated with several maternal mental health variables, namely: presence of at least one psychiatric diagnosis (odds radio [OR] 3.01, 95%CI 1.75-5.18), anxiety disorder (OR 2.06, 95%CI 1.20-3.46), affective disorder (OR 2.10, 95%CI 1.21-3.65), and mental health disorders due to use of psychoactive substances (OR 2.31, 95%CI 1.18-4.55).
CONCLUSION: The observed prevalence of child behavior problems fell within the range reported in previous studies. Maternal mental health is an important risk factor for behavior problems in preschool-aged children.

Descriptors: Child psychiatry; epidemiology; families; mood disorders, unipolar; women

9 - A cross-cultural study of gambling disorder: a comparison between women from Brazil and the United States
Gustavo C. Medeiros; Eric W. Leppink; Sarah A. Redden; Ana Yaemi; Mirella Mariani; Hermano Tavares; Jon E. Grant
Pages: 53 - 57

OBJECTIVE: To perform a cross-cultural comparison of gambling disorder (GD) in women from Brazil and the United States, two countries with pronounced social and cultural differences. We hoped to produce insight into the impact of cultural influences on the presentation of GD in women, which may be useful for the development of culturally-sensitive interventions.
METHOD: We assessed 681 women with GD: 406 from a Brazilian sample and 275 from a U.S. sample. We assessed demographic and gambling behavior variables in addition to co-occurring psychiatric disorders.
RESULTS: Fewer Brazilian participants were Caucasian (73.3 vs. 91.3%; p = 0.022). Also, Brazilian women had lower levels of education (59.9% with high school or less vs. 44.4%; p < 0.001), and were more likely to have a current partner (54.9 vs. 43.4%; p = 0.003). Brazilian gamblers also reported lower urge scores (6.6±4.3 vs. 11.6±2.4; p < 0.001) and higher chasing rates (89.1 vs. 80.0%; p = 0.002). Brazilian gamblers reported higher rates of bingo gambling (19.2 vs. 5.7%; p < 0.001), but lower rates of card game gambling (5.8 vs. 23.1%; p < 0.001). Finally, Brazilian gamblers were more likely to endorse a history of major depressive disorder (36.9 vs. 24.4%; p = 0.001).
CONCLUSIONS: This study reinforces the need for further general cross-cultural research on GD and particularly for studies investigating how gender mediates these differences. Finally, the differences noted in this analysis suggest that the findings of predominantly Anglo-Saxon cultures may not be generalizable to other world populations.

Descriptors: Gender differences; impulse control disorders; women; minority issues; cross-cultural psychiatry

10 - Crack-cocaine dependence and aging: effects on working memory
Breno Sanvicente-Vieira; Júlia Kommers-Molina; Tatiana De Nardi; Ingrid Francke; Rodrigo Grassi-Oliveira
Pages: 58 - 60

OBJECTIVE: To compare the working memory (WM) performance of young adult crack-cocaine dependent users, healthy older adults, and a control group of healthy young adults.
METHODS: A total of 77 female participants took part in this study: 26 young adult crack-cocaine dependent users (CRK), 19 healthy older adults (HO), and 32 healthy younger adults (HC). All participants completed the N-back verbal task.
RESULTS: A multivariate analysis of covariance was performed. The model included education, income, and medication use as covariates. A group effect (F6,140 = 7.192, p < 0.001) was found. Post-hoc analyses showed that the performance of the CRK and HO groups was reduced compared to the HC group in two N-back conditions. No differences between the HO and CRK groups on Wm performance were found.
CONCLUSIONS: CRK participants perform similar to HO participants on a WM task, despite the well-known effects of age on WM and the young age of CRK. These data point to a possible parallel between cognitive declines associated with crack use and developmental aging.

Descriptors: Working memory; crack cocaine; aging; substance use-related disorders; cognition

11 - What are the boundaries of legal guardianship in Alzheimer's disease? An evidence-based update in the context of the Brazilian Civil Code
Felipe K. Sudo; Ana C. Salles; Clarisse R. de Santiago
Pages: 61 - 64

The Brazilian Civil Code, which came into force in 2002, established a functional criterion for guardianship proceedings and introduced the concept of "limited guardianship," applied to cases in which incapacity to exercise civil rights is partial. With population aging and the growth in the number of older people with cognitive impairments, such as Alzheimer's disease (AD), the need to invoke legal remedies against elder abuse increased; however, difficulties in assessing capacity still lead to a majority of decisions in favor of plenary guardianship. The present article compiled data on capacity in AD subjects. The varying degrees of decision-making impairment at different stages of AD might be compatible with limited guardianship in milder cases of the disease.

Descriptors: Mental competency; civil capacity; dementia; Alzheimer disease; legal guardian

12 - Antidepressive and anxiolytic effects of ayahuasca: a systematic literature review of animal and human studies
Rafael G. dos Santos; Flávia L. Osório; José Alexandre S. Crippa; Jaime E. C. Hallak
Pages: 65 - 72

OBJECTIVE: To conduct a systematic literature review of animal and human studies reporting anxiolytic or antidepressive effects of ayahuasca or some of its isolated alkaloids (dimethyltryptamine, harmine, tetrahydroharmine, and harmaline).
METHODS: Papers published until 3 April 2015 were retrieved from the PubMed, LILACS and SciELO databases following a comprehensive search strategy and using a predetermined set of criteria for article selection.
RESULTS: Five hundred and fourteen studies were identified, of which 21 met the established criteria. Studies in animals have shown anxiolytic and antidepressive effects of ayahuasca, harmine, and harmaline, and experimental studies in humans and mental health assessments of experienced ayahuasca consumers also suggest that ayahuasca is associated with reductions in anxiety and depressive symptoms. A pilot study reported rapid antidepressive effects of a single ayahuasca dose in six patients with recurrent depression.
CONCLUSION: Considering the need for new drugs that produce fewer adverse effects and are more effective in reducing anxiety and depression symptomatology, the described effects of ayahuasca and its alkaloids should be further investigated.

Descriptors: Psychedelic agents; dimethyltryptamine; harmine; monoamine oxidase inhibitors; therapeutic use

13 - Stigma toward mental illness in Latin America and the Caribbean: a systematic review
Franco Mascayano; Thamara Tapia; Sara Schilling; Rubén Alvarado; Eric Tapia; Walter Lips; Lawrence H. Yang
Pages: 73 - 85

OBJECTIVE: Stigma toward individuals with mental disorders has been studied extensively. In the case of Latin America and the Caribbean, the past decade has been marked by a significant increase in information on stigma toward mental illness, but these findings have yet to be applied to mental health services in Latin America. The objective of this study was to conduct a systematic review of studies relating to stigma toward mental illness in Latin America and the Caribbean. The authors specifically considered differences in this region as compared with manifestations reported in Western European countries.
METHODS: A systematic search of scientific papers was conducted in the PubMed, MEDLINE, EBSCO, SciELO, LILACS, Imbiomed, and Bireme databases. The search included articles published from 2002 to 2014.
RESULTS: Twenty-six studies from seven countries in Latin America and the Caribbean were evaluated and arranged into the following categories: public stigma, consumer stigma, family stigma, and multiple stigmas.
CONCLUSION: We identified some results similar to those reported in high-income settings. However, some noteworthy findings concerning public and family stigma differed from those reported in Western European countries. Interventions designed to reduce mental illness-related stigma in this region may benefit from considering cultural dynamics exhibited by the Latino population.

Descriptors: Schizophrenia; community mental health; epidemiology; social anthropology; psychosis

14 - Hippocampus size does not correlate with body mass index in bipolar disorder
Miréia Viana-Sulzbach; Mariana Pedrini; Joana Bücker; Elisa Brietzke; Clarissa S. Gama
Pages: 86 - 87


15 - Intimate partner violence during pregnancy: case report of a forensic psychiatric evaluation
Lisieux E. de B. Telles; Alcina J. Barros; Caroline G. Moreira; Mariana R. Almeida; Mateus de B. Telles; Vivian P. Day
Pages: 87 - 88


16 - Corrigendum

Pages: 89 - 89