Ana Cristina Chaves

Validity study of the Brazilian version of the Calgary Depression Scale for Schizophrenia

INTRODUCTION Although depression is a well-established feature of schizophrenia, it is difficult to measure, because it overlaps with negative symptoms and extrapyramidal symptoms (EPS). Routinely adopted depression scales were not designed to be used in--cases of schizophrenia, and are known to perform poorly when trying to distinguish depression from other symptoms. OBJECTIVE The aim of this study was to evaluate the validity of the Brazilian version of the Calgary Depression Rating Scale for Schizophrenia (CDSS). METHOD Outpatients from four mental health units in the city of São Paulo, diagnosed as having schizophrenia by DSM-IV criteria, were evaluated by two independent raters who applied the DSM-IV depression criteria. All patients were assessed by means of the CDSS, the Positive and Negative Syndrome Scale (PANSS), and the Extrapyramidal Symptom Rating Scale (ESRS). RESULTS Eighty patients were recruited for the study. The analysis was carried out by comparing the DSM-IV criteria of depression with the CDSS scores, by means of the receiver operating characteristic (ROC) curves. The area under the ROC curve for major depression was 0.95 (SD = 0.02), and at a cut-off point of 6/7 the validity coefficients were as follows: sensibility 77%, specificity 92%, positive predictive value 67% and negative predictive value 95%. The area under the ROC curve for minor depression was 0.95 (SD = 0.02), and at a cut-off point of 4/5 the validity coefficients were as follows: sensibility 95%, specificity 88%, positive predictive value 75% and negative predictive value 98%. The correlation coefficients between the CDSS scores, the PANSS negative and positive subscale scores, and the ESRS scores were all below 0.50. CONCLUSION It can be concluded that the Brazilian version of the CDSS is a valid research tool to assess depressive episodes for stabilized patients with schizophrenia.

Depressive episodes in stable schizophrenia: critical evaluation of the DSM-IV and ICD-10 diagnostic criteria

Depressive episodes are a common and potentially severe occurrence in schizophrenia but are poorly recognised by psychiatrists. Coherent diagnostic criteria are necessary to improve diagnosis and treatment of these conditions. To evaluate the usefulness of the ICD-10 category of post-schizophrenic depression (PSD) and the DSM-IV category of postpsychotic depressive disorder of schizophrenia (PDDS), 80 clinically stable schizophrenic outpatients were evaluated with two independent measures of depression, a dimensional measure and a categorical measure. One rater applied the DSM-IV criteria for major depressive episodes (MDE), and the other applied the Calgary Depression Scale for Schizophrenia, the Positive and Negative Syndrome Scale, and the Extrapyramidal Symptoms Rating Scale. Thirteen patients (16.3%) met criteria for MDE. All of them met the DSM-IV PDDS research criteria, but only two patients matched the ICD-10 PSD criteria, which require that the episode occurred in the 12 months after the last psychotic episode. There was no significant difference in the incidence of depressive episodes within 12 months after an acute psychotic episode and outside this time period. The data suggest that depressive episodes in schizophrenia are not restricted to the first year following the psychotic episode. Useful criteria for depressive episodes in schizophrenia should avoid a temporal relation with the psychotic episode.

Diagnostic stability over one year in first-episode psychosis

Results of first-episode psychosis studies have shown that the diagnosis of schizophrenia is more stable across time than other diagnoses within the psychosis spectrum disorders. The objective of this study was to determine the diagnostic stability in a sample of first-episode patients and to determine the factors that predicted a diagnostic shift. Two hundred and twenty-eight individuals presenting for treatment with a first episode of non-affective psychosis were diagnosed at baseline and at one-year follow-up. Symptoms, functioning and cognition were also assessed. The overall consistency of diagnoses was 68% with an increase to 89% when schizophreniform was excluded. Schizophrenia was found to have the highest prospective consistency (95%), schizophreniform was less stable (36%) with shifts towards schizophrenia and other psychotic disorders were the least stable with a prospective consistency of 62%. Schizophrenia had the largest influx of cases at follow-up with a retrospective consistency of 63%. Schizophrenia can be reliably diagnosed at the initial assessment. There are clinical implications for dealing with the risk of shifting diagnosis for those who present with schizophrenia spectrum and other psychotic disorders.

Cost of schizophrenia: direct costs and use of resources in the State of São Paulo

OBJECTIVE To estimate the direct costs of schizophrenia for the public sector. METHODS A study was carried out in the state of São Paulo, Brazil, during 1998. Data from the medical literature and governmental research bodies were gathered for estimating the total number of schizophrenia patients covered by the Brazilian Unified Health System. A decision tree was built based on an estimated distribution of patients under different types of psychiatric care. Medical charts from public hospitals and outpatient services were used to estimate the resources used over a one-year period. Direct costs were calculated by attributing monetary values for each resource used. RESULTS Of all patients, 81.5% were covered by the public sector and distributed as follows: 6.0% in psychiatric hospital admissions, 23.0% in outpatient care, and 71.0% without regular treatment. The total direct cost of schizophrenia was US

Weight gain, dyslipidemia and altered parameters for metabolic syndrome on first episode psychotic patients after six-month follow-up

191,781,327 (2.2% of the total health care expenditure in the state). Of this total, 11.0% was spent on outpatient care and 79.2% went for inpatient care. CONCLUSIONS Most schizophrenia patients in the state of São Paulo receive no regular treatment. The study findings point out to the importance of investing in research aimed at improving the resource allocation for the treatment of mental disorders in Brazil.

Multi-Family Group Intervention in a Programme for Patients With First-Episode Psychosis: a Brazilian Experience

OBJECTIVES Obesity and metabolic abnormalities are frequent in psychotic patients, including first-episode psychosis. We evaluated weight and metabolic parameters in first-episode psychotic outpatients from the First Episode Psychosis Program, Universidade Federal de São Paulo. METHOD Weight, height, waist and hip circumferences, glucose and lipid levels were measured at baseline and after a six-month period. RESULTS Fifty-seven patients were included and 44 (77.2%) of them finished the study. Patients had a median age of 26.3 years, 60% were men and 43% had a diagnosis of schizophrenia at the endpoint. Weight and BMI values increased significantly during the follow-up (p < 0.01). The average weight gain at the follow-up was 10.1% of the baseline weight (SD = 11.9). Only women presented significant waist abnormalities: at the first assessment the waist mean was 79.12 cm (SD = 10.68) and 6 months later it had increased to 89.65 cm (SD = 11.19, z = -3.182, p = 0.001). After 6 months, the total cholesterol (p = 0.004), and triglyceride levels (p = 0.016) increased, while HDL-cholesterol levels decreased (p = 0.025). During the follow-up period one patient (2.3%) developed diabetes mellitus, one (2.3%) presented altered fasting glucose, 12 (27.2%) patients developed at least two altered parameters for metabolic syndrome and 3 (6.8%) patients developed metabolic syndrome (p = 0.001). DISCUSSION The results of this study showed that in a short period of time individuals under antipsychotic treatment had their weight increased significantly and developed important metabolic abnormalities. CONCLUSIONS Clinicians should be aware of these risks, choose an antipsychotic that causes less weight gain and should monitor these patients carefully, and recommend prophylactic measures as diet restriction and physical activities.

Diferenças entre os sexos na esquizofrenia

Background: Patients’ relatives are considered crucial for treatment and recovery in psychosis but family intervention studies have shown contradictory results in firstepisode psychosis. The aims of this study were to survey caregivers’ satisfaction with the multi-family intervention delivered by our programme and to verify if knowledge acquisition about illness and treatment provided by the family intervention was considered enough and understandable. Methods: Sixty five family members of 46 first-episode patients were invited to answer a satisfaction questionnaire about the intervention. Results: Forty individuals returned the questionnaire: 31 women (77.5%) and nine men (22.5%). Most (82.5%) had daily contact with the patient and 19 (47.5%) were mothers. Regarding knowledge acquisition, approximately one third did not improve their understanding of the illness. Nonetheless, 90% of the participants believed the meetings helped them to cope with their ill relative and 95% approved the multi-family format. Conclusions: Non-specific aspects of the intervention were seen as the most useful part of the programme. An important target of treatment would be to improve the way in which the specific psychoeducational components are delivered to individuals with low formal education.

Experience of recovery from a first‐episode psychosis

A proposta deste artigo e dar uma visao global e sucinta dopapel do genero em varios aspectos do transtornoesquizofrenico, e justificar por que esse tema tornou-se fre-quente na literatura psiquiatrica nessa ultima decada.Epidemiologia e aspectos clinicos das diferencas entre os sexosO ponto de origem dessa discussao foi a observacao de queos homens tem uma idade de inicio da doenca mais precoce queas mulheres. Essa observacao pode ser considerada um dosachados mais consistentes de pesquisa em esquizofrenia, e in-depende do criterio utilizado para inicio da doenca.

Family expectation, social adjustment and gender differences in a sample of schizophrenic patients

Aim: To understand the subjective factors involved in the recovery process following a first‐episode psychosis.

Fertility and fecundity of an outpatient sample with schizophrenia

A case series to study factors related to family expectation regarding schizophrenic patients was conducted in an out-patient setting in the city of S. Paulo, Brazil. Patients diagnosed as presenting schizophrenia by the ICD 9th Edition and having had the disease for more than four years were included in the study. Family Expectation was measured by the difference between the Katz Adjustment Scale (R2 and R3) scores based on the relatives expectation and the socially expected activities of the patient (Discrepancy Score), and social adjustment was given by the DSM-III-R Global Assessment Scale (GAS). Outcome assessments were made independently, and 44 patients comprised the sample (25 males and 19 females). The Discrepancy mean score was twice as high for males as for females (p < 0.02), and there was an inverse relationship between the discrepancy score and social adjustment (r = -0.46, p < 0.001). Moreover, sex and social adjustment exerted independent effects on the discrepancy score when age, age at onset and number of psychiatric admissions were controlled by means of a multiple regression technique. There was an interaction between sex and social adjustment, the inverse relationship between social adjustment and discrepancy score being more pronounced for males. These findings are discussed in the light of the potential association between the family environment, gender and social adjustment of schizophrenic patients, and the need for further research, i.e. ethnographic accounts of interactions between patient and relatives sharing households particularly in less developed countries.