Itiro Shirakawa

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.

Ayahuasca in Adolescence: A Neuropsychological Assessment

Abstract The purpose of the study was to evaluate neuropsychologically adolescents who use ayahuasca in a religious context. A battery of neuropsychological tests was administered to adolescents who use ayahuasca. These subjects were compared to a matched control group of adolescents who did not use ayahuasca. The controls were matched with regards to sex, age, and education. The neuropsychological battery included tests of speeded attention, visual search, sequencing, psychomotor speed, verbal and visual abilities, memory, and mental flexibility. The statistical results for subjects from matched controls on neuropsychological measures were computed using independent t-tests. Overall, statistical findings suggested that there was no significant difference between the two groups on neuropsychological measures. Even though, the data overall supports that there was not a difference between ayahuasca users and matched controls on neuropsychological measures, further studies are necessary to support these findings.

Decision support system for the diagnosis of schizophrenia disorders

Clinical decision support systems are useful tools for assisting physicians to diagnose complex illnesses. Schizophrenia is a complex, heterogeneous and incapacitating mental disorder that should be detected as early as possible to avoid a most serious outcome. These artificial intelligence systems might be useful in the early detection of schizophrenia disorder. The objective of the present study was to describe the development of such a clinical decision support system for the diagnosis of schizophrenia spectrum disorders (SADDESQ). The development of this system is described in four stages: knowledge acquisition, knowledge organization, the development of a computer-assisted model, and the evaluation of the systems performance. The knowledge was extracted from an expert through open interviews. These interviews aimed to explore the experts diagnostic decision-making process for the diagnosis of schizophrenia. A graph methodology was employed to identify the elements involved in the reasoning process. Knowledge was first organized and modeled by means of algorithms and then transferred to a computational model created by the covering approach. The performance assessment involved the comparison of the diagnoses of 38 clinical vignettes between an expert and the SADDESQ. The results showed a relatively low rate of misclassification (18-34%) and a good performance by SADDESQ in the diagnosis of schizophrenia, with an accuracy of 66-82%. The accuracy was higher when schizophreniform disorder was considered as the presence of schizophrenia disorder. Although these results are preliminary, the SADDESQ has exhibited a satisfactory performance, which needs to be further evaluated within a clinical setting.

Aspectos gerais do manejo do tratamento de pacientes com esquizofrenia

A esquizofrenia é um transtorno de evolução crônica. Costuma comprometer a vida do paciente, torná-lo frágil diante de situações estressantes e aumentar o risco de suicídio. Assim, exige um acompanhamento do paciente em longo prazo e que o psiquiatra faça um planejamento para segui-lo ao longo do tempo. O objetivo principal do acompanhamento psiquiátrico é a prevenção de recaídas, pois essas contribuem para a deterioração do paciente. Como objetivos secundários estão a prevenção do suicídio, a reabilitação do paciente e a diminuição do estresse familiar. O sucesso do tratamento depende da adesão do paciente. Mesmo após várias crises e remissões, os pacientes param de tomar os antipsicóticos e voltam a ter recaídas. A relação médico-paciente e o vínculo devem ser trabalhados constantemente para o êxito do acompanhamento psiquiátrico. As estratégias do tratamento variam conforme o paciente, sua família, a fase e a gravidade da doença.

Nicotine use in patients with schizophrenia evaluated by the Fagerström Tolerance Questionnaire: a descriptive analysis from a Brazilian sample.

OBJECTIVE This is a descriptive study to determine smoking prevalence rates in a convenience sample of patients with schizophrenia and to describe clinical/demographic variables for nicotine use in this population. METHOD Patients with schizophrenia were consecutively invited to answer a standard clinical/demographic questionnaire and a questionnaire on smoking habits (Fagerstrom Tolerance Questionnaire). RESULTS Eighty-three patients were interviewed. The smoking rate was 57.8% (n = 48). Male (68.8%) patients smoked more than females did (31.3%; p = 0.081). Compared to patients who smoked at the time of disease onset, those who only started smoking after disease onset had a lower mean age at the time of disease onset [24 years old (SD = +/- 6.8) vs.19 years old (SD = +/- 3.9; p = 0.041)]. Patients who preferred high-nicotine content cigarettes (p < 0.01) had higher frequency of smoking inhalation (p < 0.05) and had more urgency to smoke the first cigarette in the morning (p < 0.05). Twenty-seven (56.3%) of smoking patients were heavy smokers (FTQ > or =8). CONCLUSIONS Patients with schizophrenia in our convenience sample smoked in a higher rate compared to the general population in Brazil. Smoking patients were heavy smokers evaluated by the Fagerstrom Tolerance Questionnaire.

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

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.

Migration and mental health: Japanese Brazilians in Japan and in Brazil

OBJETIVO: O Brasil e o pais com a maior comunidade de descendentes japoneses do mundo (migracao iniciada em 1908). No entanto, mais recentemente (1988) um movimento migratorio em direcao oposta se iniciou. Muitos desses descendentes tem migrado para o Japao a trabalho e sofrem disturbios mentais. Alguns deles procuram tratamento no Japao, enquanto outros retornam ao Brasil para se tratarem. O objetivo do presente estudo e comparar o perfil sociodemografico e diagnosticos dos pacientes ambulatoriais brasileiros descendentes de japoneses que permaneceram no Japao com os que retornaram ao Brasil. METODO: Todos os pacientes ambulatoriais atendidos de forma consecutiva nas unidades psiquiatricas no Japao e no Brasil de abril de 1997 a abril de 2000 foram comparados. Os diagnosticos foram realizados por psiquiatras de acordo com a CID-10. Os dados sociodemograficos e os diagnosticos no Brasil e no Japao foram comparados por meio do Teste Qui-Quadrado. RESULTADOS: O grupo que retornou ao Brasil era principalmente de homens, nao casados, que viviam sos no Japao, tiveram uma breve estada neste pais e foram classificados no grupo de esquizofrenia. O grupo no Japao era principalmente constituido de mulheres, casadas, morando com familiares ou amigos, estada longa no Japao e foram classificadas no grupo de ansiedade. A regressao logistica mostrou que os fatores mais significativamente associados com o grupo que retornou foram o fato de morar sos e ficarem pouco tempo no Japao (OR = 0,93 e 40,21, respectivamente). CONCLUSAO: Concluimos que morar em familia e ter uma rede de amigos e muito importante para a saude mental no contexto avaliado.

How do experts recognize schizophrenia: the role of the disorganization symptom

OBJECTIVE Research on clinical reasoning has been useful in developing expert systems. These tools are based on Artificial Intelligence techniques which assist the physician in the diagnosis of complex diseases. The development of these systems is based on a cognitive model extracted through the identification of the clinical reasoning patterns applied by experts within the clinical decision-making context. This study describes the method of knowledge acquisition for the identification of the triggering symptoms used in the reasoning of three experts for the diagnosis of schizophrenia. METHOD Three experts on schizophrenia, from two University centers in Sao Paulo, were interviewed and asked to identify and to represent the triggering symptoms for the diagnosis of schizophrenia according to the graph methodology. RESULTS Graph methodology showed a remarkable disagreement on how the three experts established their diagnosis of schizophrenia. They differed in their choice of triggering-symptoms for the diagnosis of schizophrenia: disorganization, blunted affect and thought disturbances. CONCLUSIONS The results indicate substantial differences between the experts as to their diagnostic reasoning patterns, probably under the influence of different theoretical tendencies. The disorganization symptom was considered to be the more appropriate to represent the heterogeneity of schizophrenia and also, to further develop an expert system for the diagnosis of schizophrenia.

The mental health of Korean immigrants in São Paulo, Brazil

This study investigated the frequency of lifetime mental disorders among Korean immigrants in the city of São Paulo, Brazil. Snowball sampling with multiple focuses was used to recruit Korean immigrants older than 18 years and living in São Paulo. A total of 324 Korean immigrants were selected and their mental status was evaluated using a structured interview, namely the Portuguese or the Korean version of the Composite International Diagnostic Interview 2.1. The diagnoses of mental disorders were made according to the ICD-10. The frequency of any lifetime psychiatric disorder was 41.9%. The frequencies of main disorders were: anxiety disorder, 13% (post-traumatic stress disorder, 9.6%); mood disorder, 8.6%; somatoform disorders, 7.4%; dissociative disorder, 4.9%; psychotic disorder, 4.3%; eating disorder, 0.6%; any substance (tobacco, alcohol, drugs) use disorder, 23.1%. The frequency of any psychiatric disorder except alcohol and tobacco use disorders was 26.2%. Korean immigrants have more psychiatric disorders than the Korean population in Korea, particularly post-traumatic stress disorder, and almost the same rate as the Brazilian population. Mental health authorities should promote a healthier integration and the development of culturally sensitive mental health programs for Korean immigrants.