Lucas Spanemberg

Comorbidades do transtorno de déficit de atenção e hiperatividade em crianças escolares

RESUMO - O b j e t i v o: Avaliar a frequencia de transtorno de conduta (TC), transtorno desafiador opositivo ( T D O ) e transtorno obsessivo-compulsivo (TOC) em criancas com transtorno de deficit de atencao e hiperatividade ( T D A H ) .M e t o d o: Estudo realizado em criancas de 7 a 11 anos com TDAH conforme criterios do DSM-IV ( n = 3 5 ) , exame neurologico normal e exame neurologico evolutivo (ENE) segundo Lefevre alterado. Os re s p o n s a v e i s responderam a questionarios contendo os criterios do DSM-IV para TDAH e para comorbidades.R e s u l t a d o s: TDAH do tipo combinado foi o mais prevalente (51,4%). Quatorze criancas (40,0%) apresentaram TC, incluindo duas que apresentaram TC e TOC. Cinco (14,2%) apresentaram apenas TDO e uma (2,8%) apresentou apenas TOC. Onze das quatorze criancas (78,5%) com TC tinham TDAH do tipo combinado (p<0,05). Onze das quinze criancas (73,3%) sem comorbidades eram do tipo desatentas ou hiperativas (p<0,05).Conc l u s a o: O TDAH a p resenta alta frequencia de comorbidade com TC, que parece estar pre f e rencialmente associado ao TDAH combinado. PALAVRAS-CHAVE: transtorno de deficit de atencao e hiperatividade, comorbidades, criancas. Attention-deficit hyperactivity disorder comorbidity in a school sample of children

High prevalence and prescription of benzodiazepines for elderly: data from psychiatric consultation to patients from an emergency room of a general hospital.

OBJECTIVES The aim of this study is to compare the use and prescription of psychotropic drugs, with emphasis on benzodiazepines, in elderly and non-elderly patients who are assisted at the emergency room by a psychiatric consultation of a university teaching hospital. METHOD This is a cross-sectional study. We analyzed all records of psychiatric consultation in an emergency room of a general hospital from March 2009 until March 2010. Sociodemographic and clinical variables were compared between the group of elderly and non-elderly in two cutoff points (≥60 and ≥65 years), with emphasis on the use and prescription of benzodiazepines. RESULTS Five hundred seventy-five records were found with 71 elderly and 504 nonelderly for the first cutoff point and 51 elderly and 524 nonelderly in the second. Differences between groups were found in all sociodemographic variables (gender, marital status, education, current occupational status). Elderly patients treated at emergency rooms used more psychotropic drugs, particularly antidepressants and benzodiazepines, than non-elderly. About 25% of the patients received benzodiazepine treatment in the emergency setting, and there was no statistical difference between age groups. CONCLUSION There is a wide prevalence of benzodiazepine use among elderly patients in a psychiatric emergency service. Despite the recommendations for its judicious use, benzodiazepines were the most commonly used drug by psychiatrists on duty, regardless of patients age. These results call for caution in prescribing these drugs and require alternatives to the treatment of psychiatric disorders in the elderly.

Biological differences between melancholic and nonmelancholic depression subtyped by the CORE measure

Background The purpose of this study was to compare melancholic patients rated by the CORE measure of observable psychomotor disturbance with nonmelancholic and control subjects across a set of biomarkers. Methods Depressed patients were classified as melancholic or nonmelancholic by using the CORE measure. Both groups of patients, as well as control subjects, were compared for a set of clinical and laboratory measures. Serum levels of brain-derived neurotrophic factor, of two markers of oxidative stress (protein carbonyl content [PCC] and thiobarbituric acid reactive substances [TBARS]), and of several immunity markers (interleukin [IL]-2, IL-4, IL-6, IL-10, IL-17, tumor necrosis factor-alpha, and interferon-gamma) were analyzed. Results Thirty-three depressed patients and 54 healthy controls were studied. Depressive patients showed higher IL-4, IL-6, and PCC values than healthy controls. Thirteen (39%) of the depressed patients were assigned as melancholic by the CORE measure. They generated lower interferon-gamma (compared with nonmelancholic depressed patients) and TBARS (compared with both the nonmelancholic subset and controls) and returned higher IL-6 levels than controls. Both depressive groups generated higher PCC scores than controls, with no difference between melancholic and nonmelancholic subsets. Conclusion A sign-based measure to rate melancholia was able to replicate and extend biological findings discriminating melancholic depression. Signs of psychomotor disturbance may be a useful diagnostic measure of melancholia.

Depression Dimensions: Integrating Clinical Signs and Symptoms from the Perspectives of Clinicians and Patients.

Background Several studies have recognized that depression is a multidimensional construct, although the scales that are currently available have been shown to be limited in terms of the ability to investigate the multidimensionality of depression. The objective of this study is to integrate information from instruments that measure depression from different perspectives–a self-report symptomatic scale, a clinician-rated scale, and a clinician-rated scale of depressive signs–in order to investigate the multiple dimensions underlying the depressive construct. Methods A sample of 399 patients from a mood disorders outpatient unit was investigated with the Beck Depression Inventory (BDI), the Hamilton Depression Rating Scale (HDRS), and the Core Assessment of Psychomotor Change (CORE). Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were used to investigate underlying dimensions of depression, including item level analysis with factor loadings and item thresholds. Results A solution of six depression dimensions has shown good-fit to the data, with no cross-loading items, and good interpretability. Item-level analysis revealed that the multidimensional depressive construct might be organized into a continuum of severity in the following ascending order: sexual, cognitive, insomnia, appetite, non-interactiveness/motor retardation, and agitation. Conclusion An integration of both signs and symptoms, as well as the perspectives of clinicians and patients, might be a good clinical and research alternative for the investigation of multidimensional issues within the depressive syndrome. As predicted by theoretical models of depression, the melancholic aspects of depression (non-interactiveness/motor retardation and agitation) lie at the severe end of the depressive continuum.

Translation and cross-cultural adaptation of the Temperament & Personality Questionnaire into Brazilian Portuguese

INTRODUCTION The Temperament & Personality Questionnaire (T&P) is a self-report instrument designed to evaluate personality styles overrepresented in patients with depression. This report briefly describes the translation and adaptation of the T&P into Brazilian Portuguese. METHODS The procedures, which included 10 steps, followed guidelines for the adaptation of self-report instruments defined by the International Society For Pharmacoeconomics and Outcomes Research (ISPOR) Task Force for Translation and Cultural Adaptation. RESULTS The author of the original T&P questionnaire authorized and participated in the translation conducted by the authors and independent native speakers. Evaluation of the translated questionnaire indicated that only minor adjustments were required in the Portuguese version. CONCLUSIONS The Brazilian version of T&P, translated and adapted following a rigid standardized process, is available for use free of charge and may be especially useful in pursuing links between personality styles and depressive conditions.

Childhood trauma and dimensions of depression: a specific association with the cognitive domain.

Objective: To investigate associations between a history of childhood trauma and dimensions of depression in a sample of clinically depressed patients. Methods: A sample of 217 patients from a mood-disorder outpatient unit was investigated with the Beck Depression Inventory, the Hamilton Depression Rating Scale, the CORE Assessment of Psychomotor Change, and the Childhood Trauma Questionnaire. A previous latent model identifying six depressive dimensions was used for analysis. Path analysis and Multiple Indicators Multiple Causes (MIMIC) models were used to investigate associations between general childhood trauma and childhood maltreatment modalities (emotional, sexual, and physical abuse; emotional and physical neglect) with dimensions of depression (sexual, cognition, insomnia, appetite, non-interactiveness/retardation, and agitation). Results: The overall childhood trauma index was uniquely associated with cognitive aspects of depression, but not with any other depressive dimension. An investigation of childhood maltreatment modalities revealed that emotional abuse was consistently associated with depression severity in the cognitive dimension. Conclusion: Childhood trauma, and specifically emotional abuse, could be significant risk factors for the subsequent development of cognitive symptoms of major depression. These influences might be specific to this depressive dimension and not found in any other dimension, which might have conceptual and therapeutic implications for clinicians and researchers alike.

Association between core-assigned melancholia and the melancholia subscale of the HAM-D

BACKGROUND Clinical observation and research data suggest that major depression (MD) is a heterogeneous disorder, possibly representing a group of different clinical entities. The identification of more homogeneous subtypes of depression could enhance research and enable development of more specific treatments. A melancholic subtype of MD, defined by the presence of observable psychomotor disturbance (PMD), is proposed to be more homogeneous and associated with biological determinants. The aim of this study was to investigate the homogeneity of this melancholic subtype in terms of symptoms by searching for an association between melancholia and a unidimensional subscale of the Hamilton Depression Rating Scale (HAM-D) proposed to have biological validity (HAM-D6). METHODS A cross-sectional assessment of 385 outpatients presenting with a unipolar major depressive episode was carried out to evaluate depressive symptoms using the HAM-D and melancholic or nonmelancholic subtype, according to the CORE measure of PMD. RESULTS Melancholic patients exhibited more severe depressive symptoms, mainly associated with the HAM-D6. The items of this melancholia subscale represent 42.3% of the total HAM-D and were responsible for 59.4% of between-group differences. Correlation analysis showed similar results. LIMITATIONS Most patients received previous treatment, and some were not at the nadir of the episode when assessed. This could have lowered the CORE measure sensibility. CONCLUSION Melancholic depression, as assigned by the CORE measure, represents a more severe and homogeneous subtype of MD. This observation may allow identification of proper biomarkers and development of more specific treatments.

Postpartum depression: terminological considerations

Especialista em Psiquiatria. Tesoureiro, Centro de Estudos emPsiquiatria Integrada (CENESPI), e psiquiatra, Ambulatorio deAuxilio a Cessacao do Tabagismo, Hospital Sao Lucas, PontificiaUniversidade Catolica do Rio Grande do Sul (PUCRS), PortoAlegre, RS. Professor convidado, Instituto Fernando Pessoa (IFP),Porto Alegre, RS.

Dysthymia: historical/nosological characteristics and its relationship with major depressive disorder

El trastorno distimico es una forma cronica e incapacitante de depresion, que ocurre en una parcela significativa de la poblacion (3 a 6%) y aumenta los riesgos de trastorno depresivo mayor. Esta asociada a incapacitaciones considerables y elevada comorbilidad. El status nosologico de la distimia viene provocando muchas controversias a lo largo de las decadas pasadas, siendo que algunas investigaciones la consideraron como siendo un trastorno del humor y otras como un trastorno de personalidad. La nosografia actual la clasifica entre los trastornos del humor, siendo hoy una entidad tratable y que necesita de mas atencion a causa de su morbilidad. Este articulo revisa los principales aspectos historicos de la distimia, sus caracteristicas nosologicas, subtipos y su relacion con el trastorno depresivo mayor. Al final, concluimos que se necesita de nuevos estudios para validar el concepto de distimia y el espectro de depresiones cronicas, para una mejor comprension etiologica y para una terapeutica con base en evidencias.

Factors related to positive and negative outcomes in psychiatric inpatients in a General Hospital Psychiatric Unit: a proposal for an outcomes index

Background General Hospital Psychiatric Units have a fundamental importance in the mental health care systems. However, there is a lack of studies regarding the level of improvement of patients in this type of facility. Objective To assess factors related to good and poor outcomes in psychiatric inpatients using an index composed by clinical parameters easily measured. Methods Length of stay (LOS), Global Assessment of Functioning (variation and at discharge) and Clinical Global Impression (severity and improvement) were used to build a ten-point improvement index (I-Index). Records of psychiatric inpatients of a general hospital during an 18-month period were analyzed. Three groups (poor, intermediate and good outcomes) were compared by univariate and multivariate models according to clinical and sociodemographic variables. Results Two hundred and fifty patients were included, with a percentage in the groups with poor, regular and good outcomes of 16.4%, 59,6% and 24.0% respectively. Poor outcome at the discharge was associated mainly with lower education, transient disability, antipsychotics use, chief complaint “behavioral change/aggressiveness” and psychotic features. Multivariate analysis found a higher OR for diagnoses of “psychotic disorders” and “personality disorders” and others variables in relation to protective categories in the poor outcome group compared to the good outcome group. Discussion Our I-Index proved to be an indicator of that allows an easy and more comprehensive evaluation to assess outcomes of inpatients than just LOS. Different interventions addressed to conditions such as psychotic disorders and disruptive chief complaints are necessary.