Renério Fráguas Júnior

Depressão pós-AVC: fatores de risco e terapêutica antidepressiva

Depression is the most frequent psychiatric complication among stroke survivors. Several aspects have been indicated as risk factors for its occurrence. This review investigates the risk factors and the state of the art of the treatment for poststroke depression, in order to stimulate its detection and adequate treatment by the physician. The point prevalence of Major Depression after stroke varies from 10% to 34%, varying according to differences among the research methods. The length of poststroke period, characteristics of the sample, type of treatment received by patients and diagnostic criteria used can influence the reported prevalence of poststroke depression. The risk factors that have been associated with the occurrence of poststroke depression, are: functional and cognitive impairment, previous history of depression and stroke, sex, age, hypercortisolism, poor social support and stroke neuroanatomic correlates. This one has supported the formulation of a pathophysiological mechanism for poststroke depression related with prefrontosubcortical circuits and neurotransmission of biogenic amines. The depression has a harmful impact on stroke prognosis. It can cause a more severe functional impairment, retardation of the rehabilitation process, outcome complications, and a higher mortality risk. In addition, poststroke depression has not been accurately diagnosed and treated. With the advantage of the magnetic ressonance, researchers should focus investigations on the association of specific cerebral regions with the depressive manifestation and treatment response. Methodological issues such as previous history of depression and the type of the depressive manifestation should be considered for analysis.

Depression during pregnancy in women with a medical disorder: risk factors and perinatal outcomes

BACKGROUND: Approximately one‐fifth of women present depression during pregnancy and puerperium, and almost 13% of pregnant women experience a major depressive disorder. OBJECTIVE: The aim of this study was to identify risk factors for depression among pregnant women with a medical disorder and to evaluate the influence of depression on perinatal outcomes. METHODS: Three hundred and twenty‐six pregnant women with a medical disorder were interviewed. A semistructured interview was conducted for each participant using a questionnaire that had been developed previously. Major depression was diagnosed using the Portuguese version of the Primary Care Evaluation of Mental Disorders (PRIME‐MD). The medical records of the participants were thoroughly reviewed to evaluate the perinatal results. RESULTS: Major depressive disorder was diagnosed in 29 cases (9.0%). The prevalence of major depression was as follows: 7.1% for preeclampsia or chronic hypertension, 12.1% for cardiac disorder, 7.1% for diabetes mellitus, 6.3% for maternal anemia, 8.3% for collagenosis and 12.5% for a high risk of premature delivery. An univariate analysis showed a significant positive correlation between an average household income below minimum wage and a PRIME‐MD diagnosis of major depression. A multiple regression analysis identified unplanned pregnancy as an independent predictor of major depression (86.2% in the group with a diagnosis of major depression by PRIME‐MD vs. 68.4% in the group without major depression). A comparison between women who presented major depression and those who did not revealed no significant differences in the perinatal results (i.e., preterm delivery, birth weight and low Apgar scores). CONCLUSION: In the present study, unplanned pregnancy in women with a medical disorder was identified as a risk factor for major depression during gestation. Major depression during pregnancy in women with a medical disorder should be routinely investigated using specific methods.

Depressão no Hospital Geral: estudo de 136 casos

OBJETIVO: O objetivo deste estudo e investigar os sintomas depressivos que diferenciam pacientes com e sem depressao associada a condicoes medicas. METODOS: Foram estudados 293 pedidos de interconsulta a psiquiatria, consecutivos, no ano 1998, sendo 168 (57,5%) mulheres e 124 (42,5%) homens, com idades variando de 18 a 93 anos (47,2+/-18,0 anos). O diagnostico psiquiatrico foi realizado atraves de uma entrevista clinica aberta, utilizando-se os criterios do DSM-IV. A analise estatistica foi realizada atraves dos testes de Qui-quadrado e regressao logistica. RESULTADOS: Dos 293 pacientes avaliados, 230 (78,50%) preenchiam criterios para diagnostico psiquiatrico; sendo que 136(59,1%) apresentaram transtornos dentro do espectro depressivo: Depressao Maior (n=60-26,1%), Depressao Menor (n=31-13,5%), Depressao Secundaria (n=19-8,3%) e Reacao de Ajustamento com Humor Depressivo (n=26-11,3%). A excecao do aumento de apetite, aumento de peso, agitacao e ilusoes, a ocorrencia ou nao de depressao foi significativamente diferente (p<0,05) quando se comparou a presenca com a ausencia dos demais sintomas potencialmente depressivos. A anedonia e a piora matinal so foram detectadas em, respectivamente, 4 e 3 pacientes sem depressao, o que nao permitiu sua inclusao na analise de regressao logistica. De acordo com a analise de regressao logistica (IC=95%), as variaveis selecionadas para explicar o diagnostico de depressao foram: pensamento de morte (OR=20,6; 2,5-170,5), irritabilidade (OR=4,5; 1,7-11,9), despertar precoce (OR=15,0; 1,7-129,3) e perda de peso (OR=8,1; 2,6-24,4). CONCLUSAO: Pensamentos de morte, irritabilidade, despertar precoce, perda de peso anedonia e piora matinal foram os sintomas que mais fortaleceram o diagnostico de depressao. Mesmo sintomas que poderiam ser manifestacao da condicao clinica e/ou da depressao (tais como insonia, diminuicao da concentracao, fadiga e lentificacao) foram significativamente mais associados ao diagnostico da depressao. Estes dados reforcam a necessidade do clinico investigar ativamente o diagnostico de depressao na presenca de sintomas fisicos que podem ser decorrentes de uma condicao medica geral ou de uma depressao. Devido a sua elevada prevalencia, a depressao nao pode ser um diagnostico de exclusao.

Risk of suicide in high risk pregnancy: an exploratory study

OBJECTIVE To identify the risk of suicidal behavior in high-risk pregnant women at a public hospital in São Paulo. METHODS We conducted a semi-structured interview with each of the participants (n = 268) through a previously prepared questionnaire. Risk of suicidal behavior was assessed by the Portuguese version of PRIME-MD. RESULTS The mean age of patients was 29 years (SD = 0.507) and gestation period was 30 weeks (SD = 0.556). Of the total sample, specific risk of suicide was found in 5% (n = 14). Of these, 85% have a stable relationship (married or cohabitating), the pregnancy was planned in 50% of cases, and 71% have no religion or professional activities. The correlation of risk of suicide with data from marital status, planned birth, age, education, professional practice, risk of prematurity, and religion showed that having a religion is statistically significant (p = 0.012). There were no positive associations for any of the other selected variables when compared with the risk of suicide. By correlating the risk of suicide with other characteristic symptoms of major depression, there was statistical significance in the sample with regard to insomnia or hypersomnia (p = 0.003), fatigue or loss of energy (p = 0.001), decreased or increased appetite (p = 0.005), less interest in daily activities (p = 0.000), depressed mood (p = 0.000), feelings of worthlessness or guilt (p = 0.000), decreased concentration (p = 0.002), and agitation or psychomotor retardation (p = 0.002). CONCLUSION We found that religion can be a protective factor against suicidal behavior. Besides providing a social support network needed by women during pregnancy, religion supports belief in life after death and in a loving God, giving purpose to life and self esteem and providing models for coping with crises. The results show the importance of prevention and early diagnosis of suicidal behavior, since suicide is an attempt to move from one sphere to another by force, seeking to solve what seems impossible.

Risco de suicídio em gestantes de alto risco: um estudo exploratório

OBJECTIVE: To identify the risk of suicidal behavior in high-risk pregnant women at a public hospital in Sao Paulo. METHODS: We conducted a semi-structured interview with each of the participants (n = 268) through a previously prepared questionnaire. Risk of suicidal behavior was assessed by the Portuguese version of PRIME-MD. RESULTS: The mean age of patients was 29 years (SD = 0.507) and gestation period was 30 weeks (SD = 0.556). Of the total sample, specific risk of suicide was found in 5% (n = 14). Of these, 85% have a stable relationship (married or cohabitating), the pregnancy was planned in 50% of cases, and 71% have no religion or professional activities. The correlation of risk of suicide with data from marital status, planned birth, age, education, professional practice, risk of prematurity, and religion showed that having a religion is statistically significant (p = 0.012). There were no positive associations for any of the other selected variables when compared with the risk of suicide. By correlating the risk of suicide with other characteristic symptoms of major depression, there was statistical significance in the sample with regard to insomnia or hypersomnia (p = 0.003), fatigue or loss of energy (p = 0.001), decreased or increased appetite (p = 0.005), less interest in daily activities (p = 0.000), depressed mood (p = 0.000), feelings of worthlessness or guilt (p = 0.000), decreased concentration (p = 0.002), and agitation or psychomotor retardation (p = 0.002). CONCLUSION: We found that religion can be a protective factor against suicidal behavior. Besides providing a social support network needed by women during pregnancy, religion supports belief in life after death and in a loving God, giving purpose to life and self esteem and providing models for coping with crises. The results show the importance of prevention and early diagnosis of suicidal behavior, since suicide is an attempt to move from one sphere to another by force, seeking to solve what seems impossible.

Methylphenidate in a patient with depression and respiratory insufficiency.

Objective: We report a case of severe depression in an elderly and critically ill patient with multiple medical complications who was treated with a combination of methylphenidate and sertraline. The objective of this report is to outline the usefulness of methylphenidate as an antidepressant in a patient with respiratory insufficiency. Method: Case description. Results: The patient had a positive clinical response with initial mental confusion due to methylphenidate. An initial dose of 2.5 mg/day allowed antidepressant response and improvement of respiratory function permitting the removal of mechanical ventilation. Conclusion: Methylphenidate may be useful for patients with severe medical conditions including ventilatory insufficiency.

Temperament and character traits in major depressive disorder: a case control study

BACKGROUND Patients with major depressive disorder (MDD) have distinct personality traits, compared with control subjects, although the role of anxiety and positive and negative affects in this finding is unclear. DESIGN AND SETTING A case-control study enrolling 103 antidepressant-free depressed patients and 103 age and gender-matched controls was conducted at the University Hospital, University of São Paulo. METHODS The self-reported scales of the Positive and Negative Affect Schedule (PANAS), State-Trait Anxiety Inventory (STAI) and Cloningers Temperament and Character Inventory (TCI) were applied. Temperament and character traits were compared between groups using multivariate and bivariate analyses of variance (MANOVA and ANOVA). The influence of anxiety and affect was further investigated using ANOVA and mediation analyses. RESULTS Depressed patients presented higher harm avoidance and lower self-directedness scores than controls. After adjustment for anxiety trait, harm avoidance was no longer significantly different between groups. Mediation analysis revealed that the anxiety trait, but not state-anxiety or affect, fully mediated the influence of group (depressed versus control subjects) on harm avoidance. CONCLUSIONS Our findings confirm that depressed patients present personality traits distinct from those of controls and suggest that MDD is not directly associated with harm avoidance, but that this effect is fully mediated through the anxiety trait.