Tania Correa de Toledo Ferraz Alves

Perceptions of and attitudes toward antidepressants: stigma attached to their use--a review.

The aim of this study was to ascertain whether there is any evidence of stigma related to the use of antidepressants. Using the PubMed and MEDLINE databases, we searched for the terms stigma, antidepressants, and depression. A protocol was developed to extract information from the papers, which were identified and explored further. Thirty-two papers were identified. We found that the stigma against depression differs from stigma against the use of antidepressants. Stigma against depression does not impact on therapeutic adherence to antidepressant use. Stigma related to antidepressant use appears to be linked with perceived emotional weakness, severity of illness, an inability to deal with problems, and a lack of belief in the therapeutic efficacy of antidepressants. Stigma against medication can be a useful target for interventions, just like the stigma related to depression. However, clinicians must be careful in avoiding the medicalization of symptoms.

Does ragging play a role in medical student depression — Cause or effect?

BACKGROUND Medical students experience a lot of stress what may contribute to symptoms of depression. In this study we set out to look at the environmental factors which may be contributing in one medical school in Brazil. METHODS We assessed depressive symptoms using Becks Depression Inventory in 465 and 267 medical students in 2001 and 2006 respectively. We explored possible social and environmental causes using qualitative data. RESULTS Nearly 15% scored above the cut off for depression in both the samples. Males in the pre-clinical stage in 2006 showed an increase in depressive symptoms than males in the same cycle in 2001 (aOR=7.36 [95% CI=0.85-63.5] p=0.07). Qualitative data confirmed that factors such as ragging and low social involvement were correlated with depressive symptoms in pre-clinical stage males. LIMITATIONS The sample size was small both for quantitative and qualitative aspects of the study. CONCLUSIONS It appears that ragging plays an important role in the genesis of depressive symptoms in medical students.

Outcome predictors of smoking cessation treatment provided by an addiction care unit between 2007 and 2010

OBJECTIVE To analyze the predictors of smoking cessation treatment outcomes in a sample with a high rate of medical and psychiatric disorders and addictions. METHODS Analysis of predictors of success of a 6-week treatment provided by an addiction care unit (CAPS-AD) to 367 smokers in Brazil from 2007 to 2010. Forty variables were collected at baseline. Success was defined as abstinence from smoking for a period of at least 14 consecutive days, including the last day of treatment. Twenty variables were selected for the logistic regression model. RESULTS The only condition correlated with successful treatment after logistic regression was smoking ones first cigarette 5 minutes or more after waking (beta = 1.85, 95% confidence interval [95%CI] = 1.11-3.10, p = 0.018). Subjects with hypertension and alcohol use disorders and those who were undergoing psychiatric treatment showed success rates comparable to or greater than the average success rate of the sample (34.2-44.4%). CONCLUSIONS These findings support the importance of the variable time to first cigarette in treatment outcomes for a sample with a high rate of clinical and psychiatric disorders. Good success rates were observed for pharmacological treatment, which was combined with group therapy based on cognitive-behavioral concepts and integrated into ongoing treatment of other addictions and psychiatric disorders.

The link between cardiovascular risk, Alzheimer's disease, and mild cognitive impairment: support from recent functional neuroimaging studies

OBJECTIVE To review functional neuroimaging studies about the relationship between cardiovascular risk factors (CVRFs), Alzheimers disease (AD), and mild cognitive impairment (MCI). METHODS We performed a comprehensive literature search to identify articles in the neuroimaging field addressing CVRF in AD and MCI. We included studies that used positron emission tomography (PET), single photon emission computerized tomography (SPECT), or functional magnetic resonance imaging (fMRI). RESULTS CVRFs have been considered risk factors for cognitive decline, MCI, and AD. Patterns of AD-like changes in brain function have been found in association with several CVRFs (both regarding individual risk factors and also composite CVRF measures). In vivo assessment of AD-related pathology with amyloid imaging techniques provided further evidence linking CVRFs and AD, but there is still limited information resulting from this new technology. CONCLUSION There is a large body of evidence from functional neuroimaging studies supporting the hypothesis that CVRFs may play a causal role in the pathophysiology of AD. A major limitation of most studies is their cross-sectional design; future longitudinal studies using multiple imaging modalities are expected to better document changes in CVRF-related brain function patterns and provide a clearer picture of the complex relationship between aging, CVRFs, and AD.

Framingham Coronary Heart Disease Risk Score Can be Predicted from Structural Brain Images in Elderly Subjects

Recent literature has presented evidence that cardiovascular risk factors (CVRF) play an important role on cognitive performance in elderly individuals, both those who are asymptomatic and those who suffer from symptoms of neurodegenerative disorders. Findings from studies applying neuroimaging methods have increasingly reinforced such notion. Studies addressing the impact of CVRF on brain anatomy changes have gained increasing importance, as recent papers have reported gray matter loss predominantly in regions traditionally affected in Alzheimer’s disease (AD) and vascular dementia in the presence of a high degree of cardiovascular risk. In the present paper, we explore the association between CVRF and brain changes using pattern recognition techniques applied to structural MRI and the Framingham score (a composite measure of cardiovascular risk largely used in epidemiological studies) in a sample of healthy elderly individuals. We aim to answer the following questions: is it possible to decode (i.e., to learn information regarding cardiovascular risk from structural brain images) enabling individual predictions? Among clinical measures comprising the Framingham score, are there particular risk factors that stand as more predictable from patterns of brain changes? Our main findings are threefold: (i) we verified that structural changes in spatially distributed patterns in the brain enable statistically significant prediction of Framingham scores. This result is still significant when controlling for the presence of the APOE 4 allele (an important genetic risk factor for both AD and cardiovascular disease). (ii) When considering each risk factor singly, we found different levels of correlation between real and predicted factors; however, single factors were not significantly predictable from brain images when considering APOE4 allele presence as covariate. (iii) We found important gender differences, and the possible causes of that finding are discussed.

High frequency of silent brain infarcts associated with cognitive deficits in an economically disadvantaged population

OBJECTIVE: Using magnetic resonance imaging, we aimed to assess the presence of silent brain vascular lesions in a sample of apparently healthy elderly individuals who were recruited from an economically disadvantaged urban region (São Paulo, Brazil). We also wished to investigate whether the findings were associated with worse cognitive performance. METHODS: A sample of 250 elderly subjects (66-75 years) without dementia or neuropsychiatric disorders were recruited from predefined census sectors of an economically disadvantaged area of Sao Paulo and received structural magnetic resonance imaging scans and cognitive testing. A high proportion of individuals had very low levels of education (4 years or less, n=185; 21 with no formal education). RESULTS: The prevalence of at least one silent vascular-related cortical or subcortical lesion was 22.8% (95% confidence interval, 17.7–28.5), and the basal ganglia was the most frequently affected site (63.14% of cases). The subgroup with brain infarcts presented significantly lower levels of education than the subgroup with no brain lesions as well as significantly worse current performance in cognitive test domains, including memory and attention (p<0.002). CONCLUSIONS: Silent brain infarcts were present at a substantially high frequency in our elderly sample from an economically disadvantaged urban region and were significantly more prevalent in subjects with lower levels of education. Covert cerebrovascular disease significantly contributes to cognitive deficits, and in the absence of magnetic resonance imaging data, this cognitive impairment may be considered simply related to ageing. Emphatic attention should be paid to potentially deleterious effects of vascular brain lesions in poorly educated elderly individuals from economically disadvantaged environments.

THE COMBINATION OF CITALOPRAM AND RIVASTIGMINE IN THE TREATMENT OF MOOD DISORDER AND COGNITIVE IMPAIRMENT DUE TO CEREBROVASCULAR DISEASE: A CASE REPORT AND LITERATURE REVIEW

Background: Although common, mood disorder due to cerebrovascular disease is rarely diagnosed by general practitioners, despite this condition being associated with poor health outcomes and increased mortality risk in the elderly. Methods: In this case report, we sought to characterize the clinical course of a 67-year-old man with mood symptoms associated with cerebrovascular disease, treated with a combination of the selective serotonin reuptake inhibitor (SSRI) citalopram and rivastigmine, an acetylcholinesterase inhibitor (AChEI). We then provide a brief literature review on the treatment of vascular behavioral impairment. The patient was initially evaluated in a psychiatric outpatient clinic, accompanied He was admitted at a clinical hospital due his emotional state and to co-morbidities, when he received psychiatric, neurologic and general medical evaluations. Results: Following a diagnosis of a mood disorder with associated cognitive symptoms, treatment was started, combining psychotherapy and citalopram, leading to a partial response. A series of adjuctive antidepressants were added, each quickly discontinued after the patient developed various adverse effects. Given both cognitive and mood residual symptoms, rivastigmine was added to citalopram, and the combination resulted marked improvement in depression, with reduction from 23 to 7 points on the Hamilton Depressive Scale (HAM-D), and improved cognition, reflected in an increase from 25 to 28 points in the Mini-Mental State Examination (MMSE) score. The patient was followed annually for six years with both clinical and cognitive evaluations, and at the end of this time he died after a stroke and brief period of significant clinical and cognitive decline. At the time of his last psychiatric evaluation, a few months prior to his death, the patient met criteria for vascular dementia. Conclusion: In this single case report, we highlight important features of the treatment of mood disorder and cognitive due to cerebrovascular disease. A brief review of literature found studies demonstrating improvement of vascular behavioral cognitive impairment, after treatment with the combination of association of SSRIs and AChEIs. These studies point to the need for randomized controlled trials of combination treatment for this condition.

Frontal cortex and normal aging: A voxel-based morphometry MRI study of healthy individuals

for significance using a bootstrapping method (Preacher & Kelley, 2010) with 10000 iterations. Results: Both HC (P<0.005) and ERC (P<0.0001) were significantly related to DMN connectivity while controlling for age and total grey matter. HC (Figure 1A) and ERC (Figure 1B) show similar patters of relationship with the DMN at the map level. ERCmediates the relationship between HC and DMN connectivity as assessed by a bootstrapping method (mediation ratio1⁄40.42, indirect effect1⁄41.03*10 -4, confidence interval1⁄4[3.35*10 -5 to 1.83*10 -5], p<0.001). Amyloid burden did not modify this effect. Conclusions: First, we find that structural measures of the MTL affect DMN connectivity above and beyond the effects of nonspecific greymatter and age. Second,we find further evidence for a structural/functional pathway between hippocampus and the DMN that is mediated by entorhinal cortex. Longitudinal analyses will elucidate the order in which these regions are impacted during AD development.

Subtle gray matter changes involving medial temporo-parietal cortex associated to cardiovascular risk factors: A possible link to Alzheimer's disease

Battery (Ganguly et al 1996), Everyday Abilities Scale for India (Fillenbaum et al 1999) was administered on subjects.Ten ml of venous blood was collected, genomic DNA extracted, and genotyping done at apolipoprotein-E locus according to standard procedure. The DTI images were obtained on the Philips 3T Archieva MRI scanner. Fractional Anisotropy (FA) maps were extracted using FSL-FDT software package. Voxel based morphometric (VBM) analysis was performed on the FA maps using study specific custom template by applying two sample t-test, at significance level of p 1⁄4 0.001 with threshold masking of 0.2 on white matter segmented FA maps using Statistical Parametric Mapping (SPM) 5 version. Results: Between patients with AD and controls the areas of significant difference was noticed in bilateral temporal lobes, bilateral limbic lobe, Left insula, uncus, amygdala & parahippocampal regions and Right posterior cingulate region. Bilateral temporal lobe and right subgyral parietal lobe area was differing between APOE e4 carrier and non-carrier AD patients. Conclusions: Patients with AD have abnormalities in white matter tracts in regions of temporal lobe compared to controls. Apo E4 carrier status is associated with structural changes in white matter integrity in patients with AD. Findings indicate the need for further study using VBM approach in white matter tracts of patients with AD and apoE4 allele.

Cognitive Impairment and Differences Between Early and Late Onset Depression in a Sample from Outpatient Service of Geriatric Psychiatry

Background:Memory complaints are also common in older adults with depression. Cognitive impairment in late onset depression (LOD) may be a result of the depressive disorder or an underlying dementing condition. Studies suggest that LOD is more often associated with cognitive impairment than early onset depression (EOD). It also seems that incident depression and gender interact in old age. The physiological impact of depression may be greater for men than for women despite the greater prevalence of depression among women.Methods:A retrospective study with patients from the outpatient service of geriatric psychiatry (public health system) that seek medical advice due to mental health complains. All of them were evaluated by a psychiatrist. Psychiatric disorders were categorized according to International Codification of Diseases (ICD 10) criteria. Data from depressive patients were analyzed into two different groups: an early onset depression group, consisting of patients first exhibiting depressive episodes before the age of 60 years; and a late onset depression group which included patients with depressive episodes starting after the age of 60 years. We assessed vascular risk factors and co-morbidities such as high blood pressure (HBP), high cholesterol level (HCL), smoking, cerebrovascular disease (CVD), diabetes, and heart diseases. Additionally, we evaluated marital status, education and cognitive status using the Mini-Mental State Examination (MMSE). Results: A total data of 113 subjects were collected. From this sample, 25,66% (n1⁄4 29) full field criteria for LOD and 15,04% (n 1⁄4 17) for EOD. No difference between MMSE was noted (average 1⁄4 25); low level of education was noted in both groups (65,82% and 63,64% respectively, had up to 4 years of schooling). Gender difference was found: while 25,64% of women and 11,9% of men full field criteria for EOD; 23,08% and 26,19%, women and men, respectively, presented LOD. Conclusions: Differences between early and late onset depression have to be clarified in order to improve specific prevention, treatment and prognostic. Gender difference is a important feature to be analyzed. Beside of this sample not find difference between MMSE, a follow up will be conducted to evaluate the evolution of cognition in this groups.