Enrique Jadresic

Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: a randomised controlled trial.

BACKGROUND The optimum way to improve the recognition and treatment of postnatal depression in developing countries is uncertain. We compared the effectiveness of a multicomponent intervention with usual care to treat postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile. METHODS 230 mothers with major depression attending postnatal clinics were randomly allocated to either a multicomponent intervention (n=114) or usual care (n=116). The multicomponent intervention involved a psychoeducational group, treatment adherence support, and pharmacotherapy if needed. Usual care included all services normally available in the clinics, including antidepressant drugs, brief psychotherapeutic interventions, medical consultations, or external referral for specialty treatment. The primary outcome measure was the Edinburgh postnatal depression scale (EPDS) score at 3 and 6 months after randomisation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00518830. FINDINGS 208 (90%) of women randomly assigned to treatment groups completed assessments. The crude mean EPDS score was lower for the multicomponent intervention group than for the usual care group at 3 months (8.5 [95% CI 7.2-9.7] vs 12.8 [11.3-14.1]). Although these differences between groups decreased by 6 months, EPDS score remained better in multicomponent intervention group than in usual care group (10.9 [9.6-12.2] vs 12.5 [11.1-13.8]). The adjusted difference in mean EPDS between the two groups at 3 months was -4.5 (95% CI -6.3 to -2.7; p<0.0001). The decrease in the number of women taking antidepressants after 3 months was greater in the intervention group than in the usual care group (multicomponent intervention from 60/101 [59%; 95% CI 49-69%] to 38/106 [36%; 27-46%]; usual care from 18/108 [17%; 10-25%] to 11/102 [11%; 6-19%]). INTERPRETATION Our findings suggest that low-income mothers with depression and who have newly born children could be effectively helped, even in low-income settings, through multicomponent interventions. Further refinements to this intervention are needed to ensure treatment compliance after the acute phase.

Aspectos emocionales en la infertilidad: una revisión de la literatura reciente

Se entiende por infertilidad la imposibilidad de una pareja de lograr un embarazo, despues de un ano de vida sexual activa, sin uso de anticonceptivos. En Chile afecta al 15% de las parejas en edad fertil. La etiologia es variada, a veces desconocida (20%). Se ha evaluado el impacto que tiene en la pareja el diagnostico de infertilidad. Es descrito como una crisis vital, a la cual contribuyen muchos factores, y se traduce en un gran desgaste emocional, por su caracter ciclico. Se repite una y otra vez la vivencia de esperanza (al inicio del ciclo) y fracaso (cuando llega la menstruacion). Impacta el elevado costo economico del tratamiento, el sometimiento a procesos quirurgicos y la invasion a la privacidad sexual. En parejas infertiles se han encontrado sentimientos de inadecuacion, desesperacion, pena, envidia y celos hacia la mujer embarazada, miedo, perdida de la libido, disfuncion erectil, inestabilidad emocional, perdida de la autoestima, culpa, depresion e ideacion suicida. Se han descrito trastornos psicosomaticos, represion de las reacciones emocionales, deseo frenetico de adoptar un hijo rapidamente o incorporarse a algun programa de fertilizacion asistida. Luego del fracaso terapeutico, desenlace habitual (70%), el 50% de las parejas presenta alguna alteracion psicologica importante. Los autores revisan la literatura reciente sobre el tema y subrayan la necesidad de la participacion activa de los profesionales de la salud mental junto a los equipos de medicina reproductiva

Expressed emotion in the families of young people with epilepsy

The parents of 41 young people with epilepsy who were living in the same household as the patients were interviewed using the Camberwell Family Interview, and ratings of expressed emotion (EE) carried out according to standard criteria. The presence of any seizures in the 6 months prior to interview was found to be a predictor of EE (p= 0. 0017). Absolute seizure frequency, as well as presence or absence of seizures was also found to vary with the EE score. Fathers may exhibit high EE by critical comments, mothers by emotional over involvement. Although it is unclear whether high EE is the result of seizures, or whether high EE makes seizures more likely to occur, an intervention study aimed at assessing the effect of lowering parental EE levels on young peoples seizure frequency might be worth pursuing.

El conflicto de intereses en medicina: una preocupación de la Sociedad de Neurología, Psiquiatría y Neurocirugía (SONEPSYN)

La literatura medica esta prestando creciente atencion al conflicto de intereses, de modo principal aunque no exclusivo, desde la perspectiva de las relaciones entre los medicos y la industria farmaceutica. Cuando hay intereses en competencia muchas veces la posibilidad de la distorsion del juicio medico no es visible a primera vista. Deben considerarse el posible sesgo inconsciente y no intencionado de autoservicio, como los efectos de que el juicio profesional parezca influenciado, independiente de si lo esta o no. El advenimiento de la Medicina basada en la Evidencia y de la Salud Administrada plantea tensiones entre el enfoque poblacional de la medicina y las obligaciones de los medicos hacia sus pacientes individuales. Al igual que en otros paises, es necesario que las sociedades cientificas nacionales impulsen el estudio, conocimiento y difusion de aquellos factores que pueden contribuir a sesgar el juicio medico, como asimismo instituir pautas eticas locales que guien a los profesionales.

Facial Blushing: Psychiatric Management

Frequent or severe facial blushing may cause distress and impede a person’s social interactions. It often leads to fear of blushing (erythrophobia) and avoidance of social situations. Current psychiatric classifications state that blushing is a hallmark physical response of social anxiety disorder (SAD).

Facial blushing: relevance of psychiatric consultation prior to surgery.

NICE guidance recommends that endoscopic thoracic sympathectomy (ETS) may be used with ‘‘normal arrangements’’ for facial blushing based on the good evidence of efficacy in the long term and on the great distress that the condition can cause. However, it is rightly very explicit about the need for the most thorough information for patients regarding possible side effects and about the fact that the symptoms are not always relieved [1]. Also, in a recent review of current indications for thoracic sympathectomy, Hashmonai et al. [2] have stated that sympathetic ablation is an effective treatment for facial blushing, while stressing the importance of being conservative in the use of this procedure, a view we agree with. Notwithstanding, there is a major limitation of almost all studies on the efficacy of sympathectomy for facial blushing that has not been addressed so far. Most studies do not systematically screen for social anxiety disorder. Thus, there is a lack of data as to whether blushers who request sympathetic surgery for their blushing suffer from isolated blushing, without any other signs of social anxiety or if, on the contrary, they fulfil some or all the criteria for the disorder. Licht and Pilegaard [3] have stated that most of the patients who are offered ETS for blushing in Denmark suffer from isolated facial blushing. This view, we believe, has a simple explanation: it is due to the absence of thorough psychiatric screening. Our results, using rather strict diagnostic criteria (DSM-IV diagnosis of generalized social anxiety disorder ? Brief Social Phobia Scale score C20 ? Social Phobia Inventory C19), show that 91 % (220 out of 242) of consecutive patients who sought help for their blushing fulfilled criteria for social anxiety disorder [4]. Similarly, a German study found that 60 % of blushers actively searching for information about ETS on the Internet fulfilled criteria for social anxiety disorder [5]. In addition, research carried out in Finland suggests that a very high proportion of blushers undergoing ETS fulfil criteria for social anxiety disorder [6]. Given the risk of irreversible side effects from ETS (approximately 10 % of those who undergo ETS regret having the operation [3]), a psychiatric consultation prior to surgery is highly desirable. We strongly believe that mental health professionals, particularly psychiatrists with experience in treating anxiety disorders, are uniquely suited to encourage persons seeking help for their blushing to try nonsurgical options first and, likewise, to help surgeons improve their preoperative screening. This is recommendable since blushing often presents in the context of social anxiety disorder (social phobia), a condition for which evidence of treatment efficacy, both pharmacological and psychological, is widely available.