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 40 - Jan/Feb/Mar/2018


1 - Mood disorder, anxiety, and suicide risk among subjects with alcohol abuse and/or dependence: a population-based study
Carolina D.Wiener; Fernanda P. Moreira; Alethea Zago; Luciano M. Souza; Jeronimo C. Branco; Jacqueline F. de Oliveira; Ricardo A. da Silva; Luis V. Portela; Diogo R. Lara; Karen Jansen; Jean P. Oses
Pages: 1 - 5

OBJECTIVE: To evaluate the prevalence of alcohol abuse and/or dependence in a population-based sample of young adults and assess the prevalence of comorbid mood disorders, anxiety, and suicide risk in this population. METHODS: This cross-sectional, population-based study enrolled 1,953 young adults aged 18-35 years. The CAGE questionnaire was used to screen for alcohol abuse and/or dependence, with CAGE scores ≥ 2 considered positive. Psychiatric disorders were investigated through the structured Mini International Neuropsychiatric Interview (MINI). RESULTS: Alcohol abuse and/or dependence was identified in 187 (9.60%) individuals (5.10% among women and 15.20% among men). Alcohol abuse and/or dependence were more prevalent among men than women, as well as among those who used tobacco, illicit drugs or presented with anxiety disorder, mood disorder, and suicide risk. CONCLUSION: These findings suggest that alcohol abuse and/or dependence are consistently associated with a higher prevalence of psychiatric comorbidities, could be considered important predictors of other psychiatric disorders, and deserve greater public heath attention, pointing to the need for alcohol abuse prevention programs.

Descriptors: Alcohol abuse and/or dependence; anxiety; mood disorder; depression; suicide risk

2 - Bipolar disorders: is there an influence of seasonality or photoperiod?
Andrea Aguglia; Antonio Borsotti; Giuseppe Maina
Pages: 6 - 11

OBJECTIVE: To increase understanding of the influence of photoperiod variation in patients with bipolar disorders. METHODS: We followed a sample of Italian bipolar patients over a period of 24 months, focusing on inpatients. All patients admitted to the Psychiatric Inpatient Unit of San Luigi Gonzaga Hospital in Orbassano (Turin, Italy) between September 1, 2013 and August 31, 2015 were recruited. Sociodemographic and clinical data were collected. RESULTS: Seven hundred and thirty patients were included. The admission rate for bipolar patients was significantly higher during May, June and July, when there was maximum sunlight exposure, although no seasonal pattern was found. Patients with (hypo)manic episodes were admitted more frequently during the spring and during longer photoperiods than those with major depressive episodes. CONCLUSIONS: Photoperiod is a key element in bipolar disorder, not only as an environmental factor but also as an important clinical parameter that should be considered during treatment.

Descriptors: Bipolar disorder; seasonality; photoperiod; sunlight

3 - Analysis of suicide mortality in Brazil: spatial distribution and socioeconomic context
Ana P. Dantas; Ulicélia N. de Azevedo; Aryelly D. Nunes; Ana E. Amador; Marilane V. Marques; Isabelle R. Barbosa
Pages: 12 - 18

OBJECTIVE: To perform a spatial analysis of suicide mortality and its correlation with socioeconomic indicators in Brazilian municipalities. METHODS: This is an ecological study with Brazilian municipalities as a unit of analysis. Data on deaths from suicide and contextual variables were analyzed. The spatial distribution, intensity and significance of the clusters were analyzed with the global Moran index, MoranMap and local indicators of spatial association (LISA), seeking to identify patterns through geostatistical analysis. RESULTS: A total of 50,664 deaths from suicide were registered in Brazil between 2010 and 2014. The average suicide mortality rate in Brazil was 5.23/100,000 population. The Brazilian municipalities presenting the highest rates were Taipas do Tocantins, state of Tocantins (79.68 deaths per 100,000 population), Itaporã, state of Mato Grosso do Sul (75.15 deaths per 100,000 population), Mampituba, state of Rio Grande do Sul (52.98 deaths per 100,000 population), Paranhos, state of Mato Grosso do Sul (52.41 deaths per 100,000 population), and Monjolos, state of Minas Gerais (52.08 deaths per 100,000 population). Although weak spatial autocorrelation was observed for suicide mortality (I = 0.2608), there was a formation of clusters in the South. In the bivariate spatial and classical analysis, no correlation was observed between suicide mortality and contextual variables. CONCLUSION: Suicide mortality in Brazil presents a weak spatial correlation and low or no spatial relationship with socioeconomic factors.

Descriptors: Suicide; epidemiology; social and political issues; community mental health; statistics

4 - Telomere length and hTERT in mania and subsequent remission
Rugül Köse Çinar
Pages: 19 - 25

OBJECTIVE: The findings of telomere length (TL) studies in bipolar disorder (BD) are controversial. The aim of the present study was to detect TL, human telomerase reverse transcriptase (hTERT), and brain derived neurotrophic factor (BDNF) in severe mania and subsequent remission. METHODS: Twenty-one medication-free male patients and 20 age and gender matched controls were recruited. The patients were followed in the inpatient clinic, and comparisons were made between the same patients in their remission state and controls. Patients received lithium plus antipsychotics during the follow-up period. Quantitative real-time polymerase chain reaction was performed to verify leukocyte TL and whole blood hTERT gene expression levels. Serum BDNF levels were verified by enzyme-linked immunosorbent assay (ELISA). RESULTS: Compared to controls, manic patients presented shorter telomeres (p < 0.001) whose length increased with treatment (p = 0.001). Patients in the late stages showed shorter TL than those in the early stages and controls (p < 0.001). hTERT gene expression levels were up-regulated in mania and remission compared to controls (p = 0.03 and p = 0.01, respectively). BDNF changes did not reach statistically significant levels. CONCLUSIONS: TL and hTERT gene expression might reflect a novel aspect of BD pathophysiology and TL might represent a novel biomarker for BD staging.

Descriptors: Bipolar disorder; telomere; TERT protein

5 - Effectiveness evaluation of mood disorder treatment algorithms in Brazilian public healthcare patients
Ana F. Lima; Sandro R. Miguel; Mírian Cohen; Jacques J. Zimmermann; Flávio M. Shansis; Luciane N. Cruz; Patrícia K. Ziegelmann; Carisi A. Polanczyk; Marcelo P. Fleck
Pages: 26 - 34

OBJECTIVE: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. METHODS: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). RESULTS: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ~ 6 years and the use of mood stabilizers began ~ 12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. CONCLUSIONS: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. CLINICAL TRIAL REGISTRATION: NCT02901249, NCT02870283, NCT02918097

Descriptors: Mood disorders; bipolar; mood disorders; unipolar; clinical drug studies; economic issues; epidemiology

6 - Schizophrenia and work: aspects related to job acquisition in a follow-up study
Larissa C. Martini; Jair B. Barbosa Neto; Beatriz Petreche; Ana O. Fonseca; Fernanda V. dos Santos; Lílian Magalhães; Alessandra G. Marques; Camila Soares; Quirino Cordeiro; Cecília Attux; Rodrigo A. Bressan
Pages: 35 - 40

OBJECTIVE: Work is considered one of the main forms of social organization; however, few individuals with schizophrenia find work opportunities. The purpose of this study was to evaluate the relationship between schizophrenia symptoms and job acquisition. METHOD: Fifty-three individuals diagnosed with schizophrenia from an outpatient treatment facility were included in an 18-month follow-up study. After enrollment, they participated in a prevocational training group. At the end of training (baseline) and 18 months later, sociodemographic, clinical data and occupational history were collected. Positive and negative symptoms (Positive and Negative Syndrome Scale - RANSS), depression (Calgary Depression Scale), disease severity (Clinical Global Impression - CGI), functionality (Global Assessment of Functioning - GAF), personal and social performance (Personal and Social Performance - RSR) and cognitive functions (Measurement and Treatment Research to Improve Cognition in Schizophrenia - MATRICS battery) were applied at baseline and at the end of the study. RESULTS: Those with some previous work experience (n=19) presented lower scores on the PANSS, Calgary, GAF, CGI and PSP scales (p < 0.05) than those who did not work. Among those who worked, there was a slight worsening in positive symptoms (positive PANSS). CONCLUSIONS: Individuals with less severe symptoms were more able to find employment. Positive symptom changes do not seem to affect participation at work; however, this calls for discussion about the importance of employment support.

Descriptors: Schizophrenia; work; symptom; support

7 - Indirect self-destructiveness in individuals with schizophrenia
Konstantinos Tsirigotis
Pages: 41 - 47

OBJECTIVE: To explore the indirect self-destructiveness syndrome in patients with schizophrenia. METHODS: Two hundred individuals with paranoid schizophrenia (117 men and 83 women, mean age 37.15 years), all in remission, were examined using the Polish version of the Chronic Self-Destructiveness Scale. Two hundred well-matched healthy individuals served as a control group. RESULTS: The intensity of indirect self-destructiveness was greater in the schizophrenia group than in controls. The intensity of each manifestation was as follows (in decreasing order): helplessness and passiveness in the face of difficulties (A5), personal and social neglects (A3), lack of planfulness (A4), poor health maintenance (A2), transgression and risk (A1). CONCLUSION: Patients with schizophrenia displayed more behaviors that were indirectly self-destructive than healthy controls; they scored better than healthy controls only on caring for their own health. The patients showed the lowest intensity of behaviors connected with the active form of indirect selfdestructiveness, and the highest intensity of behaviors connected with the passive form. These findings may enable delivery of more effective forms of pharmacological and psychosocial help to patients with schizophrenia.

Descriptors: Schizophrenia; indirect self-destructiveness; health maintenance; neglects; planfulness; helplessness

8 - Prevalence, clinical correlates and maternal psychopathology of deliberate self-harm in children and early adolescents: results from a large community study
André R. Simioni; Pedro M. Pan; Ary Gadelha; Gisele G. Manfro; Jair J. Mari; Eurípedes C. Miguel; Luis A. Rohde; Giovanni A. Salum
Pages: 48 - 55

OBJECTIVES: Little is known about the prevalence and correlates of deliberate self-harm (DSH) in children from low- and middle-income countries. We investigated the prevalence of DSH and its clinical and maternal psychopathological associations in Brazilian children (n=2,508, ages 6-14y) in a community-based study. METHODS: Participants of the High Risk Cohort Study for the Development of Childhood Psychiatric Disorders (HRC) and their mothers were assessed in structured interviews. Current (last month) and lifetime DSH were estimated, including analysis stratified by age groups. Logistic regressions were performed to investigate the role of the children,s clinical diagnoses and maternal psychopathology on DSH prevalence estimates, adjusting for potential confounding factors. RESULTS: The prevalence of current DSH was 0.8% (children 0.6%, adolescents 1%) and lifetime DSH was 1.6% (1.8% and 1.5%, respectively). Current and lifetime DSH were more frequent in children with depression, attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), even in multiple models accounting for demographic variables and co-occurring psychiatric disorders. Maternal anxiety disorder was strongly associated with current and lifetime DSH in offspring; whereas current DSH, specifically in young children, was associated with maternal mood disorder. CONCLUSION: Diagnoses of depression, ADHD and ODD were consistently associated with DSH, as was having a mother with anxiety disorder.

Descriptors: Deliberate self-harm; self-injurious behavior; suicide attempt; community survey; family health; psychopathology

9 - Correlations between caregiver psychiatric symptoms and offspring psychopathology in a low-resource setting
Camila T. Matsuzaka; Milton L. Wainberg; Andrea Norcini Pala; Elis V. Hoffmann; Bruno M. Coimbra; Rosaly F. Braga; Cristiane S. Duarte; Annika C. Sweetland; Marcelo F. Mello
Pages: 56 - 62

OBJECTIVE: Associations between parental/caregiver depression and adverse child outcomes are well established and have been described through one or more mechanisms: child psychopathology following exposure to a depressed caregiver, child psychopathology exacerbating a caregiver's depression, and caregiver and offspring depression sharing the same etiology. Data from low and middle-income countries is scarce. We examined correlations between common symptoms of mental disorders in caregivers and their offspring's psychopathology in a Brazilian sample. METHODS: In this cross-sectional study, adult caregivers were screened for depression during routine home visits by community health workers as part of the Brazilian Family Health Strategy. Caregivers with suspected depression were assessed using the Zung Self-Rating Depression Scale and the SelfReporting Questionnaire (SRQ-20). Children's symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ). RESULTS: The sample included 68 primary caregivers and 110 children aged 6 to 15 years. Higher caregiver scores on the SRQ-20 correlated significantly with psychiatric symptoms in offspring. CONCLUSION: These results substantiate our hypothesis that child psychopathology correlates with caregivers' psychiatric symptoms. This paper adds to the growing literature on community mental health assessment and can help guide future strategies for reducing the burden of common mental disorders in caregivers and children alike in low and middle-income countries.

Descriptors: Depressive disorder; primary health care; child; caregivers; Brazil

10 - Maternal recognition of child mental health problems in two Brazilian cities
Isabel A. Bordin; Bartira M. Curto; Joseph Murray
Pages: 63 - 71

OBJECTIVE: To identify child behaviors and types of impairment that increase the likelihood of maternal recognition of emotional/behavioral problems (EBP) in children and adolescents. METHODS: Maternal-reported data were obtained from two subsamples of 11-to-16-year-olds derived from cross-sectional studies conducted in two Brazilian municipalities: Itaboraí, state of Rio de Janeiro (n=480), and Embu, state of São Paulo (n=217). The Itaboraí study involved a representative sample of 6-to-16-year-olds (n=1,248; response rate = 86.0%) selected from the Family Health Program registry, which covered 85.5% of the municipal population. The Embu study was based on a probabilistic sample of clusters of eligible households (women aged 15-49 years, child < 18 years), with one mother-child pair selected randomly per household (n=813; response rate = 82.4%). The outcome variable was mother's opinion of whether her child had EBP. Potential correlates included types of child behaviors (hyperactivity/conduct/emotional problems as isolated or combined conditions) and impairment, assessed using the Strengths and Difficulties Questionnaire (SDQ); child's age and gender; maternal education and anxiety/depression (assessed using the Self-Reporting Questionnaire [SRQ]). RESULTS: Multivariate regression models identified the following correlates of maternal perception of child EBP: comorbidity (co-occurring hyperactivity/conduct/emotional problems), emotional problems alone, and interference of problems with classroom learning and friendships. CONCLUSION: Comorbidity of different problem types, emotional problems alone, and interference with classroom learning and friendships increase the likelihood of maternal recognition of EBP in children.

Descriptors: Adolescents; child psychiatry; epidemiology; families; community mental health

11 - Dysfunctional eating behaviors, anxiety, and depression in Italian boys and girls: the role of mass media
Barbara Barcaccia; Viviana Balestrini; Angelo M. Saliani; Roberto Baiocco; Francesco Mancini; Barry H. Schneider
Pages: 72 - 77

OBJECTIVE: Extensive research has implicated identification with characters in mass media in the emergence of disordered eating behavior in adolescents. We explored the possible influence of the models offered by television (TV) on adolescents' body image, body uneasiness, eating-disordered behavior, depression, and anxiety. METHODS: Three hundred and one adolescents (aged 14-19) from southern Italy participated. They completed a questionnaire on media exposure and body dissatisfaction, the Eating Disorder Inventory-2, the Body Uneasiness Test, the Beck Depression Inventory, and the State-Trait Anxiety Inventory -Form Y. RESULTS: The main factors contributing to females' eating-disordered behaviors were their own desires to be similar to TV characters, the amount of reality and entertainment TV they watched, and the discrepancy between their perceptions of their bodies and those of TV characters. Friends' desire to be similar to TV characters contributed most to depression, anxiety, body uneasiness, and eating disorders for both males and females. CONCLUSION: Our data confirm that extensive watching of reality and entertainment TV correlates with eating-disordered behavior among females. Moreover, the well-known negative effects of the media on adolescents' eating-disordered behaviors may also be indirectly transmitted by friends who share identification with TV characters.

Descriptors: Adolescents; eating disorders; child psychiatry; women; gender differences

12 - Empathic skills and theory of mind in female adolescents with conduct disorder
Olber E. Arango Tobón; Antonio Olivera-La Rosa; Viviana Restrepo Tamayo; Isabel C. Puerta Lopera
Pages: 78 - 82

OBJECTIVE: Most studies on conduct disorder (CD) have focused on male adolescents, disregarding analysis of this psychopathology in women. The purpose of this study was to identify differences in empathy and theory of mind (ToM) in a group of adolescent women with CD and a control group. METHOD: Thirty-six adolescent women were selected from an initial sample of 239 adolescents (CD group = 18, control group = 18). Empathy and ToM were evaluated through objective instruments. Mean comparisons and multivariate analysis were performed to ascertain differences between cases and controls and to propose a prediction model based on clinical status. RESULTS: Significant differences in empathic abilities and ToM were found between the groups. The model that differentiated both groups was composed of eye-reading ability, perspective taking, and personal distress. CONCLUSION: These findings are consistent with previous studies. Capacity to take the other's perspective and the recognition of emotions in the face are protective factors against CD in women.

Descriptors: Conduct disorder; empathy; theory of mind; women; callous unemotional traits

13 - Further evidence of psychological factors underlying choice of elective cesarean delivery by primigravidae
Nasrin Matinnia; Mohammad Haghighi; Leila Jahangard; Faisal B. Ibrahim; Hejar A. Rahman; Ali Ghaleiha; Edith Holsboer-Trachsler; Serge Brand
Pages: 83 - 88

OBJECTIVE: Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched. METHODS: A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs. RESULTS: Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support. CONCLUSIONS: The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

Descriptors: Elective cesarean delivery; vaginal delivery; psychological predictors; Health Belief Model; fear; stress

14 - Predictors of length of stay in an acute psychiatric inpatient facility in a general hospital: a prospective study
Fernanda L. Baeza; Neusa S. da Rocha; Marcelo P. Fleck
Pages: 89 - 96

OBJECTIVE: There have been significant reductions in numbers of psychiatric beds and length of stay (LOS) worldwide, making LOS in psychiatric beds an interesting outcome. The objective of this study was to find factors measurable on admission that would predict LOS in the acute psychiatric setting. METHODS: This was a prospective, observational study. RESULTS: Overall, 385 subjects were included. The median LOS was 25 days. In the final model, six variables explained 14.6% of the variation in LOS: not having own income, psychiatric admissions in the preceding 2 years, high Clinical Global Impression and Brief Psychiatric Rating Scale scores, diagnosis of schizophrenia, and history of attempted suicide. All variables were associated with longer LOS, apart from history of attempted suicide. CONCLUSIONS: Identifying patients who will need to stay longer in psychiatric beds remains a challenge. Improving knowledge about determinants of LOS could lead to improvements in the quality of care in hospital psychiatry.

Descriptors: Outcome studies; inpatient psychiatry; chronic psychiatric illness; administration; other delivery issues

15 - Clinical improvement in patients with borderline personality disorder after treatment with repetitive transcranial magnetic stimulation: preliminary results
Julian Reyes-López; Josefina Ricardo-Garcell; Gabriela Armas-Castañeda; María García-Anaya; Iván Arango-De Montis; Jorge J. González-Olvera; Francisco Pellicer
Pages: 97 - 104

OBJECTIVE: Current treatment of borderline personality disorder (BPD) consists of psychotherapy and pharmacological interventions. However, the use of repetitive transcranial magnetic stimulation (rTMS) could be beneficial to improve some BPD symptoms. The objective of this study was to evaluate clinical improvement in patients with BPD after application of rTMS over the right or left dorsolateral prefrontal cortex (DLPFC). METHOD: Twenty-nine patients with BPD from the National Institute of Psychiatry, Mexico, were randomized in two groups to receive 15 sessions of rTMS applied over the right (1 Hz, n=15) or left (5 Hz, n=14) DLPFC. Improvement was measured by the Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity Over Time (BEST), Beck Depression Inventory (BDI),Hamilton Anxiety Rating Scale (HAM-A), and Barratt Impulsiveness Scale (BIS). RESULTS: Intragroup comparison showed significant (p < 0.05) reductions in every psychopathologic domain of the CGI-BPD and in the total scores of all scales in both groups. CONCLUSIONS: Both protocols produced global improvement in severity and symptoms of BPD, particularly in impulsiveness, affective instability, and anger. Further studies are warranted to explore the therapeutic effect of rTMS in BPD. CLINICAL TRIAL REGISTRATION: NCT02273674.

Descriptors: Borderline personality disorder; neurophysiology; neurosciences; psychosocial factors

16 - Depression and psychodynamic psychotherapy
Ângela Ribeiro; João P. Ribeiro; Orlando von Doellinger
Pages: 105 - 109

Depression is a complex condition, and its classical biological/psychosocial distinction is fading. Current guidelines are increasingly advocating psychotherapy as a treatment option. Psychodynamic psychotherapy models encompass a heterogeneous group of interventions derived from early psychoanalytic conceptualizations. Growing literature is raising awareness in the scientific community about the importance of these treatment options, as well as their favorable impact on post-treatment outcomes and relapse prevention. Considering the shifting paradigm regarding treatment of depressive disorder, the authors aim to provide a brief overview of the definition and theoretical basis of psychodynamic psychotherapy, as well as evaluate current evidence for its effectiveness.

Descriptors: Depressive disorder; mood disorders, unipolar; psychotherapy; psychoanalysis and psychodynamic therapies

17 - Maintenance use of ketamine for treatmentresistant depression: an open-label pilot study
Ivan Barenboim; Beny Lafer
Pages: 110 - 110


18 - Skin picking disorder comorbid with ADHD successfully treated with methylphenidate
Camila Bernardes; Paulo Mattos; Bruno Palazzo Nazar
Pages: 110 - 111


19 - Is the regulation of Z-drugs In Brazil in line with scientific research and international standards?
Viviam Vargas de Barros; Emérita S. Opaleye; Ana R. Noto
Pages: 112 - 112


20 - Zika virus infection and psychosis
Beuy Joob; Viroj Wiwanitkit
Pages: 113 - 113