Fernando Madalena Volpe

The Portuguese version of the Clinical Global Impression - Schizophrenia Scale: validation study

OBJECTIVES The Clinical Global Impression-Schizophrenia Scale was designed to assess severity and treatment response in subjects with schizophrenia involved in naturalistic studies and daily clinical practice. The objective of this study is to validate the Portuguese version of the Clinical Global Impression-Schizophrenia Scale in Brazil by assessing its psychometric properties. METHOD Cross-sectional validation study of the Portuguese version of the Clinical Global Impression-Schizophrenia Scale, tested in outpatients and inpatients with schizophrenia (DSM-IV, ICD-10) from 6 centers in Brazil. Concurrent validity and sensitivity to change were assessed by comparison with the Positive and Negative Syndrome Scale, which is considered the gold standard tool to evaluate patients with schizophrenia. Interrater reliability was evaluated by intraclass correlation coefficients (ICC) calculated based on the scoring of two concomitant raters. RESULTS 70 inpatients and 70 outpatients were evaluated. Total Clinical Global Impression-Schizophrenia Scale and Positive and Negative Syndrome Scale scores were highly correlated (r=0.79; p<0.01). Positive (r=0.86), negative (r=0.79), depressive (r=0.66) and cognitive (r=0.75) symptoms subscale scores were also correlated between both scales (p<0.01). Sensitivity to change was significantly correlated between the Clinical Global Impression-Schizophrenia Scale and Positive and Negative Syndrome Scale (r=0.73; p<0.01). Interrater reliability was substantial for positive symptoms and total scores of the Clinical Global Impression-Schizophrenia Scale (ICC=0.81 and 0.73), and moderate for negative, depressive, and cognitive symptoms score (0.64, 0.67 and 0.63, respectively). CONCLUSIONS The Brazilian version of the Clinical Global Impression-Schizophrenia Scale is a valid and reliable instrument for the assessment of severity and treatment response in schizophrenic inpatient and outpatients.

Seasonal influences on admissions for mood disorders and schizophrenia in a teaching psychiatric hospital in Egypt.

BACKGROUND Distinct seasonal variation in hospital admission and various associations with the climatic parameters for mood disorders and schizophrenia have been previously reported in several world regions. There are, however, no North-African studies on this association. METHODS The charts of 1987 patients with mood disorders (mania 1181, depression 806) and 1359 patients with schizophrenia admitted from 2003 to 2007 from an university hospital at Mansoura, Egypt, were reviewed. Seasonality was assessed with Cosinor Analysis. Correlations of the rate of admissions for affective disorders and schizophrenia to climatic variables were performed, including lagged and differenced data. RESULTS There was a significant seasonal variation in the monthly admission frequencies both for mania (peak in June) and for depression (peak in December) but no significant seasonal variation was found in admissions with diagnosis of schizophrenia. The number of admissions for mania was positively correlated to indicators of temperature and luminosity, but inversely correlated to relative humidity. Quite the opposite, the number of admissions for depression showed a negative correlation to temperature and luminosity, but a positive correlation to relative humidity. 55-57% of the monthly variance of the number of admissions for mood disorders was explained by climatic variables. CONCLUSIONS Seasonality of admissions for mood disorders, but not for schizophrenia, has been demonstrated, in an African Mediterranean region with a fairly constant climate. The association between admission rates and climatic variables found in this study could pave the way for further studies aiming at exploration of the biological mechanism of this association as well as tailoring of treatment interventions on mood disorders.

Naturalistic evaluation of inpatient treatment of mania in a private Brazilian psychiatric hospital

OBJECTIVE To describe the clinical practices on the treatment of mania in a Brazilian hospital, and to compare them to other international similar reports and practice guidelines. METHODS Chart revision of 425 consecutive admissions (269 patients) for the treatment of manic or mixed episodes (ICD-10 criteria) in a private psychiatric hospital of Belo Horizonte, Brazil, from 1996 to 2000. The rates of utilization of each antimanic medication and ECT were compared to those reported in similar international observational studies (X2, bicaudate, alpha =0.05). RESULTS The observed frequencies of use of each treatment modality were: lithium (71.5%); carbamazepine (34.8%); valproate (9.4%); antipsychotics (83.3%); benzodiazepines (62.4%); antidepressants (7.5%) and ECT (33.2%). The differences detected between local practice and international guidelines were: lower rate of valproate and higher rate of carbamazepine prescription; the use of sine wave devices for ECT; frequent concomitant use of ECT with lithium (72.3%), benzodiazepines (46.8%) and/or carbamazepine (31.2%). CONCLUSIONS These results suggest the need to develop national practice guidelines for the treatment of mania and for the use of ECT, and to promote their propagation through specific medical educational programs, aiming at the standardization of practices based on the available scientific evidence.

Vasculite cerebral e uso de cocaína e crack

Cocaine and crack abuse is strongly related to stroke, particularly in young patients. The present study reports the case of a cocaine and crack abuser who developed central nervous system vasculitis, resulting in extensive cerebral infarctions, leading to dementia, behavioural disturbances and seizures. The relevance of detecting drug abuse in young stroke patients is stressed. Assessing possible brain lesions in drug abusers with cognitive impairment is also important.

Manic patients receiving ECT in a Brazilian sample

BACKGROUND Characterization of manic inpatients receiving electroconvulsive therapy (ECT) has not been done. METHODS The charts of 425 consecutive admissions of 269 inpatients treated for manic or mixed episodes, between 1996 and 2000, in a Brazilian private psychiatric hospital were reviewed. A logistic model was built to determine the predictors of use of ECT for mania. Median total length of stay (LOS) and LOS deducted from the delay until ECT was started were compared between ECT and non-ECT admissions. The risk of readmission was estimated using Coxs regression. RESULTS Significant predictors of ECT prescription were: history of previous admission (OR=4.09), psychotic features (OR=1.60), female gender (OR=2.04), married (OR=1.79), and treatment by a psychiatrist who assisted more than 20 manic inpatients in the index period (OR=1.97). Co-morbidity with cardiovascular disease was negatively associated with ECT use (OR=0.49). Median LOS after starting ECT was similar to that of non-ECT admissions (12 vs. 13 days). ECT reduced (HR=0.678) and previous psychiatric admissions increased (HR=2.320) the risk of readmission after a manic episode. LIMITATIONS Only one hospital was included in this study. CONCLUSIONS The presence of psychotic features and violent behavior during manic episodes and indicators of chronicity of bipolar illness (history of previous admissions, duration of disease) were predictors of ECT use for the treatment of mania. Suicidality was not associated with the use of ECT for mania. LOS after ECT was started was similar to LOS of non-ECT admissions. The use of ECT for mania reduced the risk of readmission.

Impact of ECT on duration of hospitalizations for mania.

Objective To assess the impact of the use of electroconvulsive therapy (ECT) on the length of hospital stay of manic patients. Materials and Methods We reviewed 425 consecutive admissions of 269 patients with manic or mixed affective episodes in a Brazilian private psychiatric hospital. Lengths of stay (LOSs) were compared for admissions in which ECT versus exclusive pharmacologic treatment was administered. A mixed model for repeated measures was developed to control for intraindividual correlations and potential demographic, clinical, and treatment confounder variables. The analyses were repeated using LOS minus the time until ECT was first given in each admission (LOS-tECT) as the response variable. Results Use of ECT was associated with longer LOS than exclusive pharmacologic treatment (18.78 versus 12.51 days; p < 0.001). This effect disappeared when using LOS-tECT as the response variable (11.57 versus 12.16 days; p = 0.530). Violent behavior and in-hospital use of antipsychotics and benzodiazepines were also associated with longer LOS, whereas being married was associated with shorter LOS. Conclusion The use of ECT during hospitalizations for mania was associated with longer lengths of stay. This effect was caused mostly by delays in commencing ECT treatments rather than by the duration of treatment itself.

Suicide and meteorological factors in São Paulo, Brazil, 1996-2011: a time series analysis

Objective: Considering the scarcity of reports from intertropical latitudes and the Southern Hemisphere, we aimed to examine the association between meteorological factors and suicide in São Paulo. Method: Weekly suicide records stratified by sex were gathered. Weekly averages for minimum, mean, and maximum temperature (°C), insolation (hours), irradiation (MJ/m2), relative humidity (%), atmospheric pressure (mmHg), and rainfall (mm) were computed. The time structures of explanatory variables were modeled by polynomial distributed lag applied to the generalized additive model. The model controlled for long-term trends and selected meteorological factors. Results: The total number of suicides was 6,600 (5,073 for men), an average of 6.7 suicides per week (8.7 for men and 2.0 for women). For overall suicides and among men, effects were predominantly acute and statistically significant only at lag 0. Weekly average minimum temperature had the greatest effect on suicide; there was a 2.28% increase (95%CI 0.90-3.69) in total suicides and a 2.37% increase (95%CI 0.82-3.96) among male suicides with each 1 °C increase. Conclusion: This study suggests that an increase in weekly average minimum temperature has a short-term effect on suicide in São Paulo.

Relationship between anhedonia and impulsivity in schizophrenia, major depression and schizoaffective disorder

BACKGROUND Anhedonia and impulsivity are prominent symptoms of many psychiatric disorders and may indicate worse prognosis, notably in schizophrenia and major depression. Despite the convergence of negative outcomes from both dimensions, the relationship between anhedonia and impulsivity in psychiatric disorders has been seldom directly assessed. The objective of the present study is to examine the correlations between anhedonia and impulsivity in three diagnostic groups: major depression, schizophrenia and schizoaffective disorder. SAMPLING AND METHODS 121 outpatients (Mansoura University Hospital, Egypt) with major depressive disorder (N=29), schizophrenia (N=59), and schizoaffective disorder (N=33), were assessed and responded to the Beck Depression Inventory, Barrats Impulsivity Scale-11, and Chapmans Social and Physical Anhedonia Scales. RESULTS Physical and social anhedonia scores were negatively correlated to impulsivity scores in major depression patients. Conversely, higher scores in physical and social anhedonia predicted higher impulsivity scores in schizophrenia. No correlations between impulsivity and anhedonia were evidenced among schizoaffectives. CONCLUSION The relationship between self-reported physical and social anhedonia and impulsivity is diagnosis-specific.

Perfil da clientela atendida em um serviço público de urgência psiquiátrica no município de Belo Horizonte, Brasil, no período de 2002 a 2007

OBJETIVO: Descrever as caracteristicas sociodemograficas, o numero e os tipos de atendimentos realizados em um servico publico de atendimento de Urgencia Psiquiatrica de Belo Horizonte, Brasil, no periodo de 2002 a 2007. METODOS: Estudo descritivo de series temporais, com analises de tendencia por meio de regressoes lineares, em que a variavel resposta foi o numero anual de atendimentos (totais e por tipo) ou a proporcao de atendimentos por diagnostico e a variavel preditora foi o ano. RESULTADOS: O numero total de atendimentos no periodo pesquisado nao apresentou alteracao significativa, embora tenha ocorrido uma reducao do numero de primeiras consultas no servico, com aumento do numero de retornos. Foi observada reducao dos diagnosticos associados a alcool e drogas de abuso e predominância dos transtornos psicoticos. CONCLUSAO: No periodo estudado, o Hospital Galba Velloso - FHEMIG manteve o volume total de atendimentos, mas observou-se reducao da proporcao de pacientes oriundos da capital, bem como reducao da procura por diagnosticos associados a alcool e drogas de abuso, enquanto a categoria diagnostica mais prevalente foi a dos transtornos psicoticos. Houve reducao dos primeiros atendimentos e das internacoes prolongadas.

Electroconvulsive therapy (ECT) effective for psychotic recrudescence and suicidality after varenicline adjunctive therapy for smoking cessation in a schizoaffective patient

Dear Editor, Schizoaffective patients present the highest rates of smoking and heavy smoking among all diagnostic groups, including schizophrenia and bipolar disorder. Smoking cessation is a major treatment objective, but many patients experience difficulties and relapse. Adjunctive pharmacotherapy with varenicline brings new hopes. A 56-year-old schizoaffective obese woman, with arterial hypertension and mild chronic obstructive pulmonary disease was frustrated in previous attempts to quit smoking, either with the aid of psychosocial treatment alone or combined with nicotine gum and patch. Bupropion had to be discontinued due to the irruption of manic symptoms. Her mother had bipolar I disorder. From age 18 (first psychiatric hospitalization), haloperidol was the main antipsychotic drug for thirty years. She did not want to quit during these initial years, and smoked up to 100 cigarettes per day. Adherence to psychiatric treatment was incomplete, with eight lifethreatening suicide attempts. In subsequent years, haloperidol was substituted for lithium plus ziprasidone, improving compliance and stability. Thirty months later, she started to express a desire to quit cigarettes. Varenicline was titrated from 0.5mg once a day to 1mg twice a day, and the first month passed with only minor mood changes. In the second month, the following escalating mixed symptomatology built up rapidly: increased energy, logorrhea, grandiosity, irritability, impulsivity, voices commenting on her, paranoid ideation, nihilistic ideas about the future, intense selfcriticism, frequent crying, and continuous suicidal ideation, with a specific plan. She recovered with 6 bilateral, bitemporal ECT sessions. As for the consequences attributable to varenicline, she later evaluated such treatment as highly beneficial and valuable to her health. She now completed two years of tobacco abstinence. Varenicline-aided smoking cessation treatment may have had a role in triggering psychotic recrudescence and suicidal behavior. Current smoking, smoking cessation, and medications for smoking cessation (bupropion, rimonabant, and varenicline) were all previously associated with suicide. Schizoaffective disorder is also significantly associated with suicide. Cigarette smoking decreases serotonin turnover and inhibits brain monoamine oxidase, increasing impulsivity and suicidality in a recently abstinent schizoaffective patient. Mood improving and antidepressant augmenting properties of varenicline have been previously described, and such a drug might concur to generate unstable mood. Particular vulnerabilities to nicotine, nicotine abstinence, and varenicline might be determined by variants of the nAChR gene recently found in schizoaffective disorder, which might favor fast built up of impulsivity and suicidality with varenicline use. GABA-A receptor beta subunits, GABRB4 and GABR1, could also be envolved. According to the American Psychiatric Association, ECT is currently the best treatment for a rapid response to psychosis or suicidality. In spite of this, ECT has no visibility in the literature of smoking cessation treatments. We recommend that ECT be considered for psychotic recrudescence and suicidality in the context of varenicline adjunct therapy for smoking cessation in schizoaffective patients.