Rafael Bernardon Ribeiro

Oxcarbazepine for self-mutilating bulimic patients

Self-mutilation behaviour (SMB) prevalence rates in the general population and in clinical samples are estimated at around 4% and 21% respectively (Guertin et al., 2001). Explanatory models describe SMB as a substitute for emotional pain (anger and tension), regarding it as either: (1) an attention-seeking behaviour; (2) a protection against suicidal tendencies, by means of stress relief and partial satisfaction of self-destructive drives; (3) an orgasm replacement in sexually repressed individuals; (4) a means of gaining control over otherwise inexpressible feelings; (5) an identity-building behaviour, against a feeling of emptiness; (6) a way to set the boundaries of the body and self (Suyemoto, 1998). SMB differs from suicidal behaviour regarding intent, frequency and methods used for self-inflicted harm. The association with developmental disorders, mental retardation and cluster B personality disorders (impulsive subtype), is common.

Clinical characteristics and outcomes on discharge of women admitted to a Medium Secure Unit over a 4-year period

There are limited data on women in Medium Secure settings. This study aimed to address this by assessing the characteristics of 45 consecutive admissions to the female ward of a Medium Secure Unit in the United Kingdom over a four-year period. Data on demographics, clinical outcomes and from HONOS-Secure/HONOS and HCR-20 assessments were prospectively collected. Psychiatric diagnoses were recorded using ICD-10 criteria. Data on quality of life from WHO-QoL-BREF surveys were analysed. There was a high proportion of ethnic minorities (57.8%), high rates of childhood and adult abuse and low socioeconomic status. 62.2% of the patients had schizophrenia, 57.8% had multiple diagnoses. The median length of stay at discharge was 465.5 days. There were statistically significant reductions in rates of self-harm and HoNOS-Secure/HoNOS and HCR-20 scores following intervention. Scores on WHO-QoL-BREF compared favourably to a large-scale sample with mental health difficulties. Many characteristics of this sample were comparable to samples from similar populations. However the particularly high proportion of ethnic minorities suggested that the profile of our patients differs from nationwide samples. Intervention by our service was associated with reduced self-harm and improvements in well-defined clinical outcomes and quality of life measures using validated scales.

Electroconvulsive therapy in Brazil after the "psychiatric reform": a public health problem--example from a university service.

Objectives The Brazilian public health system does not provide electroconvulsive therapy (ECT), which is limited to a few academic services. National mental health policies are against ECT. Our objectives were to analyze critically the public policies toward ECT and present the current situation using statistics from the Institute of Psychiatry of the University of São Paulo (IPq–HCFMUSP) and summary data from the other 13 ECT services identified in the country. Methods Data regarding ECT treatment at the IPq–HCFMUSP were collected from January 2009 to June 2010 (demographical, number of sessions, and diagnoses). All the data were analyzed using SPSS 19, Epic Info 2000, and Excel. Results During this period, 331 patients were treated at IPq–HCFMUSP: 221 (67%) were from São Paulo city, 50 (15.2%) from São Paulo’s metropolitan area, 39 (11.8%) from São Paulo’s countryside, and 20 (6.1%) from other states; 7352 ECT treatments were delivered—63.0% (4629) devoted entirely via the public health system (although not funded by the federal government); the main diagnoses were a mood disorder in 86.4% and schizophrenia in 7.3% of the cases. Conclusions There is an important lack of public assistance for ECT, affecting mainly the poor and severely ill patients. The university services are overcrowded and cannot handle all the referrals. The authors press for changes in the mental health policies.

Morbidity and mortality due to mental disorders in Brazil

During a recent research, while checking the official epide-miological database, hosted by the Brazilian Health Ministry (DATASUS: www.datasus.gov.br), some interesting infor-mation emerged. In determining morbidity and mortality directly related to Mental Disorders (based on World Health Organization - International Classification of Diseases [ICD 10]; “Chapter V - mental and behavioral disorders”), the following data was retrieved (Table 1).From a national perspective, in 2006, 2007, 2008 and 2009 (latest available data) Brazil had respectively 10,256, 10,948, 11,560 and 11,861 deaths reported with mental disorders as the main cause. This represents, respectively, 5.49, 5.78, 6.09 and 6.19 deaths

Cardiovascular safety of the method of limits titration procedure for electroconvulsive therapy dosing: a retrospective study

The best way to select the charge to be given during electroconvulsive therapy (ECT) treatment is still controversial. Although the method of limits titration procedure developed by Sackeim et al. is generally accepted as the best one, being encouraged by the American Psychiatric Association, many practitioners have concerns regarding the cardiac safety of this method. Subthreshold stimuli used during titration induce parasympathetic autonomic release that is not compensated by the sympathetic response because of seizure induction and leads to bradycardia, sometimes with asystole . In the current study, we retrospectively evaluated the medical charts of all patients who have undergone ECT with the titration procedure in a Brazilian ECT Service (University of Sao Paulo) during the year of 2007. Special emphasis was devoted to analyze the incidence of cardiac complications, especially bradycardia and asystole.

Efficacy of electroconvulsive therapy augmentation for partial response to clozapine: a pilot randomized ECT – sham controlled trial

Abstract Background: Thirty percent of schizophrenia patients are treatment-resistant. Objective : This is a single-blinded sham-controlled trial to assess the efficacy of electroconvulsive therapy (ECT) as augmentation strategy in patients with clozapine-resistant schizophrenia. Methods : Twenty three subjects were randomly assigned to 12 sessions of ECT (N = 13) or placebo (Sham ECT) (N = 10). The primary outcome was improvement on psychotic symptoms as measured by the mean reduction of the PANSS positive subscale. The assessments were performed by blind raters. Results: At baseline both groups were similar, except for negative and total symptoms of the PANSS, which were higher in the Sham group. At the endpoint both groups had a significant decrease from basal score. In the ECT group the PANSS total score decreased 8.78%, from 81.23 to 74.75 (p = 0.042), while the positive subscale had a mean reduction of 19% (19.31 to 16.17, p = 0.006). In the Sham group, the mean reduction of PANSS total score was 15.27% (96.80 to 87.43; p = 0.036), and the PANSS positive subscale decreased 27.81% (22.90 to 19.14, p = 0.008). The CGI score in ECT group decreased 23.0% (5.23 to 4.17; p = 0.001) and decreased 24.31% in the Sham ECT group (5.80 to 4.86; p = 0.004).

Public health system and psychiatry in the treatment of 'dangerous' young offenders in Brazil

We describe the Experimental Health Unit, a special forensic mental health facility in Brazil, created by court order and administered by the São Paulo Department of Health. It was designed for young offenders receiving compulsory inpatient treatment for severe personality disorders. All nine patients admitted to date came from Foundation CASA (a socio-educational centre of assistance for adolescents, the juvenile correctional centres managed by the São Paulo state Department of Justice). The court decision is questionable, relying on a new interpretation of the Child and Adolescent Statute and the law that regulates psychiatric treatment in Brazil. The public health system and psychiatry have been supporting the isolation of some individuals from society, based on the seriousness of their crimes and possession of particular personality characteristics. The decision to commit and send a small group of personality disordered individuals to this unit as inpatients is an unfair decision, since jails and correctional centres hold a high number of psychopathic who have also committed barbaric crimes. The central mental health issue is the role that the public health system should play in the custody of dangerous people; the cost-effectiveness of this model, the accuracy of risk assessment and tractability of people with severe personality disorders are also debatable. From a legal perspective, the operation of this facility raises questions about age of legal majority, the maximum period of incarceration of young offenders and use of whole-life sentences for certain types of crimes and criminals in Brazil.

Presidential pardon and mentally ill offenders detained in forensic hospitals.

The presidential pardon is a Brazilian tradition enacted every Christmas season by federal decree. An inheritance from Portuguese tradition, the Imperial pardon was incorporated into the first Brazilian constitution, of 1824, and remains a presidential prerogative according to the 1988 Federal Constitution. In 2008, this merciful regulation included, for the first time, mentally ill offenders detained in forensic hospitals (decree 6076/2008). Since then, it has been renewed on an annual basis. According to the Brazilian Penal Code (1940, revised 1984), when a defendant is unable to understand the illicit nature of his or her acts or is incapable to behave in accordance with his or her understanding, he or she will be found ‘‘unimputable’’ (not subject to criminal responsibility). Defendants thus found will be pronounced not guilty by reason of insanity (NGRI) and sentenced to compulsory treatment, a type of criminal commitment known as a ‘‘safety measure.’’ The modality of treatment and its length are determined by law. An annual psychiatric risk assessment is required, as patients held under a safety measure are, by legal definition, ‘‘dangerous.’’ However, the new presidential decrees (issued from 2008 on) explicitly do not require a medical examination for a full pardon. These presidential decisions have been confirmed by two superior courts: the São Paulo State Court and the Superior Tribunal of Justice, in Brasilia. These peculiar decrees and upcoming sentences raise a series of questions. First, patients in safety measure are sent to a forensic hospital for treatment, not for punishment. Thus, the logical rationale would be to follow a multidisciplinary treatment plan and discharge them only when properly treated. If this is not accomplished, some patients will be released when still under treatment, to the detriment of their best interests. Second, the forensic population is a heterogeneous one, and comprises from chronic mental patients who have committed minor offenses to psychopathic serial killers. Thus, these decisions can be a mistake from both the human rights and social security standpoints; the former because some pardoned patients are released to the ‘‘freedom of the streets’’ or removed to non-forensic psychiatric hospitals. As it is widely known, these hospitals do not have secure facilities, and their staff lacks expertise in treating forensic patients. Depending on their clinical characteristics, these patients can put the staff and other patients at risk, clearly contradicting Law 10.216/01 and basic human rights. Disregarding the risk assessment (the ‘‘cessation of dangerousness’’ examination) will place a large number of citizens at risk, since some dangerous criminals may be released only to commit new offences. Since these patients were declared NGRI, is the presidential pardon applicable? Is it ethical and legal to cease ongoing treatment abruptly? Should the safety of society and the routines of non-secure hospitals be put aside? The authors do hope that legislators will seek guidance from mental health professionals regarding the field of mental health, and, furthermore, that future instances of the presidential pardon take into account professional opinions when dealing with mentally ill offenders.

Availability and public policies for electroconvulsive therapy in Brazil.

To the Editor: We thank the precious comments and considerations by our colleagues Volpe et al (2013), which come in good time to complement our article regarding electroconvulsive therapy (ECT) in Brazil.1,2 Indeed, our groups have been in touch and discussed the matter, methodology, and limitations for each study. The referred Brazilian Psychiatric Association (ABP) survey was a pioneer initiative to ascertain the availability of ECT in Brazilian mental health system, public and private sectors, carried out in 2006. All existing services reported by ABP cells were included, encompassing 49 centersVa much higher number than ours (14 public services). Our survey, however, focused on highlighting public policies and accessibility to ECT treatment within Brazilian public health system (Unified Health System), on which 75.0% of our population depend. Of notice is that an ECT session at a private service in Brazil costs from US

A randomized, double-blind clinical trial on the efficacy of cortical direct current stimulation for the treatment of major depression

250.00 to US