Effectiveness of pharmacological treatments for severe agitation in real-world emergency settings: protocol of individual-participant-data network meta-analysis.

BACKGROUND: Severe psychomotor agitation and aggression often require immediate pharmacological intervention, but clear evidence-based recommendations for choosing among the multiple options are lacking. To address this gap, we plan a systematic review and individual-participant-data network meta-analysis to investigate their comparative effectiveness in real-world emergency settings with increased precision. METHODS: We will include randomized controlled trials investigating intramuscular or intravenous pharmacological interventions, as monotherapy or in combination, in adults with severe psychomotor agitation irrespective of the underlying diagnosis and requiring rapid tranquilization in general or psychiatric emergency settings. We will exclude studies before 2002, those focusing on specific reasons for agitation and placebo-controlled trials to avoid concerns related to the transitivity assumption and potential selection biases. We will search for eligible studies in BIOSIS, CENTRAL, CINAHL Plus, Embase, LILACS, MEDLINE via Ovid, PubMed, ProQuest, PsycINFO, ClinicalTrials.gov, and WHO-ICTRP. Individual-participant data will be requested from the study authors and harmonized into a uniform format, and aggregated data will also be extracted from the studies. At least two independent reviewers will conduct the study selection, data extraction, risk-of-bias assessment using RoB 2, and applicability evaluation using the RITES tool. The primary outcome will be the number of patients achieving adequate sedation within 30 min after treatment, with secondary outcomes including the need for additional interventions and adverse events, using odds ratios as the effect size. If enough individual-participant data will be collected, we will synthesize them in a network meta-regression model within a Bayesian framework, incorporating study- and participant-level characteristics to explore potential sources of heterogeneity. In cases where individual-participant data are unavailable, potential data availability bias will be explored, and models allowing for the inclusion of studies reporting only aggregated data will be considered. We will assess the confidence in the evidence using the Confidence in Network Meta-Analysis (CINeMA) approach. DISCUSSION: This individual-participant-data network meta-analysis aims to provide a fine-tuned synthesis of the evidence on the comparative effectiveness of pharmacological interventions for severe psychomotor agitation in real-world emergency settings. The findings from this study can greatly be provided clearer evidence-based guidance on the most effective treatments. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023402365.

Brazilian version of the European Cross-Cultural Neuropsychological Test Battery (CNTB-BR): diagnostic accuracy across schooling levels

Objective: To translate, establish the diagnostic accuracy, and standardize the Brazilian Portuguese version of the European Cross-Cultural Neuropsychological Test Battery (CNTB) considering schooling level. Methods: We first completed an English-Brazilian Portuguese translation and back-translation of the CNTB. A total of 135 subjects aged over 60 years - 65 cognitively healthy (mean 72.83, SD = 7.71; mean education 9.42, SD = 7.69; illiterate = 25.8%) and 70 with Alzheimer's disease (AD) (mean 78.87, SD = 7.09; mean education 7.62, SD = 5.13; illiterate = 10%) - completed an interview and were screened for depression. The receiver operating characteristic (ROC) analysis was used to verify the accuracy of each CNTB test to separate AD from healthy controls in participants with low levels of education (≤ 4 years of schooling) and high levels of education (≥ 8 years of schooling). The optimal cutoff score was determined for each test. Results: The Recall of Pictures Test (RPT)-delayed recall and the Enhanced Cued Recall (ECR) had the highest power to separate AD from controls. The tests with the least impact from schooling were the Rowland Universal Dementia Assessment Scale (RUDAS), supermarket fluency, RPT naming, delayed recall and recognition, and ECR. Conclusions: The Brazilian Portuguese version of the CNTB was well comprehended by the participants. The cognitive tests that best discriminated patients with AD from controls in lower and higher schooling participants were RPT delayed recall and ECR, both of which evaluate memory.

Aggregation of behavioral risk factors to noncommunicable chronic diseases: A national school-based study with Brazilian adolescents.

There is an increasing interest in the study of the aggregation of risk factors for noncommunicable chronic diseases. However, there are no studies among adolescents stratified by alcohol use. This study investigated the aggregation of cardiovascular risk factors in adolescents considering the use or not of alcohol. A total of 73,624 Brazilian adolescents aged 12-17 years from public and private schools were evaluated in a national cross-sectional study (March-2013 to December-2014). The aggregation of cardiovascular risk factors was the main outcome. The regression model was adjusted for sex, age, region of Brazil, and school type. Most alcohol users were 16 to 17 years old, while nonusers were between 12 and 13 years. Alcohol users showed a higher prevalence of smoking (8.1% vs. 0.8%) and sleep inadequacy (59.9% vs. 51.4%) than nonusers did. On the other hand, a sufficient level of physical activity was more frequent among alcohol users (51.2% vs. 44.2%). The presence of only one cardiovascular risk factor was more frequent in nonusers (42.3%) than alcohol users (38.9%). Alcohol users tended to aggregate more for the category of 3-4 cardiovascular risk factors when compared with the non-alcohol-using population (10.9% vs. 7.9%). Aggregation of three cardiovascular risk factors was more likely to be observed among male adolescent alcohol users. Inadequate sleep and smoking habit tended to aggregate among alcohol users. This finding highlights the importance of public policies aiming to reduce alcohol consumption at early ages and, consequently, to decrease the risk of future morbimortality of noncommunicable chronic diseases.

Brazilian version of the European Cross-Cultural Neuropsychological Test Battery (CNTB-BR): diagnostic accuracy across schooling levels.

OBJECTIVE: To translate, establish the diagnostic accuracy, and standardize the Brazilian Portuguese version of the European Cross-Cultural Neuropsychological Test Battery (CNTB) considering schooling level. METHODS: We first completed an English-Brazilian Portuguese translation and back-translation of the CNTB. A total of 135 subjects aged over 60 years - 65 cognitively healthy (mean 72.83, SD = 7.71; mean education 9.42, SD = 7.69; illiterate = 25.8%) and 70 with Alzheimer's disease (AD) (mean 78.87, SD = 7.09; mean education 7.62, SD = 5.13; illiterate = 10%) - completed an interview and were screened for depression. The receiver operating characteristic (ROC) analysis was used to verify the accuracy of each CNTB test to separate AD from healthy controls in participants with low levels of education (≤ 4 years of schooling) and high levels of education (≥ 8 years of schooling). The optimal cutoff score was determined for each test. RESULTS: The Recall of Pictures Test (RPT)-delayed recall and the Enhanced Cued Recall (ECR) had the highest power to separate AD from controls. The tests with the least impact from schooling were the Rowland Universal Dementia Assessment Scale (RUDAS), supermarket fluency, RPT naming, delayed recall and recognition, and ECR. CONCLUSIONS: The Brazilian Portuguese version of the CNTB was well comprehended by the participants. The cognitive tests that best discriminated patients with AD from controls in lower and higher schooling participants were RPT delayed recall and ECR, both of which evaluate memory.

Is Strength Training as Effective as Aerobic Training for Depression in Older Adults? A Randomized Controlled Trial.

BACKGROUND: This study aimed to compare the effects of aerobic training (AT), strength training (ST) and low-intensity exercise in a control group (CG) as adjunct treatments to pharmacotherapy for major depressive disorder (MDD) in older persons. METHODS: Older persons clinically diagnosed with MDD (n = 27) and treated with antidepressants were blindly randomized into three groups: AT, ST and a CG. All patients were evaluated prior to and 12 weeks after the intervention. RESULTS: Compared with the CG, the AT and ST groups showed significant reductions in depressive symptoms (treatment -response = 50% decrease in the pre- to postintervention assessment) through the Hamilton Depression Rating Scale (AT group: χ2, p = 0.044) and Beck Depression Inventory (ST group: χ2, p = 0.044). CONCLUSION: Adding AT or ST with moderate intensity to the usual treatment promoted a greater reduction of MDD symptoms.

PTSD in mental health outpatient settings: highly prevalent and under-recognized

Objectives: To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training. Methods: We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records. Results: Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals. Conclusions: These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

PTSD in mental health outpatient settings: highly prevalent and under-recognized.

OBJECTIVES: To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training. METHODS: We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records. RESULTS: Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals. CONCLUSIONS: These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

Diagnosing dementia in lower educated older persons: validation of a Brazilian Portuguese version of the Rowland Universal Dementia Assessment Scale (RUDAS)

Objective: To validate the Rowland Universal Dementia Assessment Scale for use in Brazil (RUDAS-BR). Methods: We first completed an English-Brazilian Portuguese translation and back-translation of the RUDAS. A total of 135 subjects over 60 years of age were included: 65 cognitively healthy and 70 with Alzheimer's disease (AD) according to the DSM-IV and Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria. All participants completed an interview and were screened for depression. The receiver operating characteristic curves of the RUDAS were compared with those of the Mini Mental State Examination (MMSE) regarding the sensitivity and specificity of cutoffs, taking education into consideration. Results: The areas under the curve were similar for the RUDAS-BR (0.87 [95%CI 0.82-0.93]) and the MMSE (0.84 [95%CI 0.7-0.90]). RUDAS-BR scores < 23 indicated dementia, with sensitivity of 81.5% and specificity of 76.1%. MMSE < 24 indicated dementia, with sensitivity of 72.3% and specificity of 78.9%. The cutoff score was influenced by years of education on the MMSE, but not on the RUDAS-BR. Conclusions: The RUDAS-BR is as accurate as the MMSE in screening for dementia. RUDAS-BR scores were not influenced by education. The RUDAS-BR may improve the cognitive assessment of older persons who are illiterate or of lower educational attainment.

Reappraising the dimensional structure of the PTSD Checklist: lessons from the DSM-IV-based PCL-C

Objective: The dimensional structure of posttraumatic stress disorder (PTSD) has been extensively debated, but the literature is still inconclusive and contains gaps that require attention. This article sheds light on hitherto unvisited methodological issues, reappraising several key models advanced for the DSM-IV-based civilian version of the PTSD Checklist (PCL-C) as to their configural and metric structures. Methods: The sample comprised 456 women, interviewed at 6-8 weeks postpartum, who attended a high-complexity facility in Rio de Janeiro, Brazil. Confirmatory factor analysis (CFA) and exploratory structural equation models (ESEM) were used to evaluate the dimensional structure of the PCL-C. Results: The original three-factor solution was rejected, along with the four-factor structures most widely endorsed in the literature (PTSD-dysphoria and PTSD-numbing models). Further exploration supported a model comprised of two factors (re-experience/avoidance and numbing/hyperarousal). Conclusion: These findings are at odds with the dimensional structure proposed in both DSM-IV and DSM-5. This also entails a different presumption regarding the latent structure of PTSD and how the PCL should be operationalized.

Diagnosing dementia in lower educated older persons: validation of a Brazilian Portuguese version of the Rowland Universal Dementia Assessment Scale (RUDAS).

OBJECTIVE: To validate the Rowland Universal Dementia Assessment Scale for use in Brazil (RUDAS-BR). METHODS: We first completed an English-Brazilian Portuguese translation and back-translation of the RUDAS. A total of 135 subjects over 60 years of age were included: 65 cognitively healthy and 70 with Alzheimer's disease (AD) according to the DSM-IV and Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria. All participants completed an interview and were screened for depression. The receiver operating characteristic curves of the RUDAS were compared with those of the Mini Mental State Examination (MMSE) regarding the sensitivity and specificity of cutoffs, taking education into consideration. RESULTS: The areas under the curve were similar for the RUDAS-BR (0.87 [95%CI 0.82-0.93]) and the MMSE (0.84 [95%CI 0.7-0.90]). RUDAS-BR scores < 23 indicated dementia, with sensitivity of 81.5% and specificity of 76.1%. MMSE < 24 indicated dementia, with sensitivity of 72.3% and specificity of 78.9%. The cutoff score was influenced by years of education on the MMSE, but not on the RUDAS-BR. CONCLUSIONS: The RUDAS-BR is as accurate as the MMSE in screening for dementia. RUDAS-BR scores were not influenced by education. The RUDAS-BR may improve the cognitive assessment of older persons who are illiterate or of lower educational attainment.

Reappraising the dimensional structure of the PTSD Checklist: lessons from the DSM-IV-based PCL-C.

OBJECTIVE: The dimensional structure of posttraumatic stress disorder (PTSD) has been extensively debated, but the literature is still inconclusive and contains gaps that require attention. This article sheds light on hitherto unvisited methodological issues, reappraising several key models advanced for the DSM-IV-based civilian version of the PTSD Checklist (PCL-C) as to their configural and metric structures. METHODS: The sample comprised 456 women, interviewed at 6-8 weeks postpartum, who attended a high-complexity facility in Rio de Janeiro, Brazil. Confirmatory factor analysis (CFA) and exploratory structural equation models (ESEM) were used to evaluate the dimensional structure of the PCL-C. RESULTS: The original three-factor solution was rejected, along with the four-factor structures most widely endorsed in the literature (PTSD-dysphoria and PTSD-numbing models). Further exploration supported a model comprised of two factors (re-experience/avoidance and numbing/hyperarousal). CONCLUSION: These findings are at odds with the dimensional structure proposed in both DSM-IV and DSM-5. This also entails a different presumption regarding the latent structure of PTSD and how the PCL should be operationalized.

Prevalence and Correlates of Elder Abuse in São Paulo and Rio de Janeiro.

OBJECTIVES: To assess the prevalence of elder abuse and to investigate potential sociodemographic, health behavior, and medical correlates. DESIGN: Cross-sectional data were collected in face-to-face assessments. SETTING: São Paulo and Rio de Janeiro, Brazil. PARTICIPANTS: Individuals aged 60 to 75. MEASUREMENTS: Information on elder abuse was obtained using the Brazil-adapted, nine-item Hwalek-Sengstock Elder Abuse Screening Test. Sampling design-adjusted descriptive statistics and logistic regression were used in analyses. RESULTS: The overall prevalence of abuse was 14.4% (n = 46/259, 95% confidence interval (CI) = 9.82-20.61) in São Paulo and 13.3% (n = 27/197, 95% CI = 8.76-19.74) in Rio de Janeiro. Unadjusted analyses indicated that poor education, low physical activity, unemployment, heart disease, and psychiatric problems were associated with abuse, but in adjusted analyses, self-reported elder abuse was significantly associated only with psychiatric problems (São Paulo: OR = 4.48, 95% CI = 1.75-11.45; Rio de Janeiro: OR = 21.61, 95% CI = 6.39-73.14). CONCLUSION: Elder abuse is prevalent in São Paulo and Rio de Janeiro, but whether concomitants of abuse are cause, effect, or both is unclear because this was a cross-sectional study. These findings highlight the importance of the problem, as well as the need to develop measures to increase awareness, facilitate prevention, and fight against abuse of elderly adults.

The worldwide incidence of neonaticide: a systematic review.

Neonaticide is the killing of a neonate on the day of its birth by his/her own mother. Neonaticidal women were reported to be predominantly young, unmarried, and primiparous. The motive for murdering the newborn relates to the shame, the fear of rejection, and abandonment by significant others, and the social stigmas associated with an illegitimate birth. The goal of the present study was to conduct a systematic review of the scientific literature and identify population-based studies reporting the incidence of neonaticide in different countries. A total of 485 abstracts were screened. After applying the inclusion/exclusion criteria, 10 studies were selected. Additional searches identified two more articles. Most of these studies were from Europe, where incidence varied from 0.07 (Finland, 1980-2000 period) to 8.5 neonaticides per 100000 births (Austria, 1975-2001 period). More recent studies have indicated that a growing proportion of neonaticidal women are married, multiparous, and suffers from mental disorders. Preventive measures, such as anonymous free delivery, were shown to reduce the incidence of neonaticide, although this effect may be short-lived. Despite social and institutional changes, neonaticide persists even in the most socially advanced, liberal, and prosperous societies in the world.

Impact and Effectiveness of 10 and 13-Valent Pneumococcal Conjugate Vaccines on Hospitalization and Mortality in Children Aged Less than 5 Years in Latin American Countries: A Systematic Review.

BACKGROUND: Several Latin American and Caribbean (LAC) countries have introduced pneumococcal conjugate vaccine (PCV-10 or PCV-13) in their routine national immunization programs. OBJECTIVES: We aimed to summarize the evidence of PCV impact and effectiveness in children under 5 years old in the LAC Region. METHODS: We conducted a systematic review of the literature on impact or effectiveness of PCVs on deaths or hospitalizations due to invasive pneumococcal disease (IPD), pneumonia, meningitis and sepsis. We searched Medline, WoS, Lilacs, Scopus, Central and gray literature published in any language from 2009 to January 2016. We included studies addressing the outcomes of interest in children in the target age group, and with the following designs: randomized trials, cohort or case-control, interrupted time series with at least three data points before and after the intervention, and before-after studies. Screening of citations, data extraction, and risk of bias assessment were conducted in duplicate by independent reviewers, according to the study protocol registered on PROSPERO. Descriptive analysis of the effectiveness measurements and sensitivity analysis were conducted. Effectiveness is reported as 1-OR or 1-RR for case control or cohort/clinical trials, and as percent change of disease incidence rates for before-after studies. RESULTS: We identified 1,085 citations, 892 from databases and 193 from other sources. Of these, 22 were further analyzed. Studies were from Brazil, Chile, Uruguay, Argentina, Peru and Nicaragua. Effectiveness ranged from 8.8-37.8% for hospitalizations due to X-ray confirmed pneumonia, 7.4-20.6% for clinical pneumonia, and 13.3-87.7% for meningitis hospitalizations, and 56-83.3% for IPD hospitalization, varying by age, outcome definition, type of vaccine and study design. CONCLUSIONS: Available evidence to date indicates significant impact of both PCV-10 and PCV-13 in the outcomes studied, with no evidence of the superiority of one vaccine over the other on pneumonia, IPD or meningitis hospitalization reduction in children under 5 years old.

Conditional risk for posttraumatic stress disorder in an epidemiological study of a Brazilian urban population.

INTRODUCTION: Conditional risk for PTSD is the risk of developing PTSD after exposure to traumatic events. This epidemiological study of the general urban population from the two largest cities in Brazil reports exposure to traumatic events; conditional risk for PTSD; and proportion/estimated number of PTSD cases secondary to each type of traumatic event. METHOD: Cross-sectional study of general population (15-75 y.o.) from Rio de Janeiro and São Paulo. PTSD was assessed through Composite International Diagnostic Interview 2.1. RESULTS: Our main findings, from 3744 participants, were: 1) high prevalence of traumatic events (86%), urban violence being the most common; 2) conditional risk for PTSD was 11.1%; 3) women (15.9%) have overall conditional risk 3 times higher than men (5.1%); 4) war-related trauma (67.8%), childhood sexual abuse (49.1%) and adult sexual violence (44.1%) had the highest conditional risks; 5) 35% of PTSD cases (estimated 435,970 individuals) were secondary to sudden/unexpected death of a close person, and 40% secondary to interpersonal violence. CONCLUSIONS: Brazilian urban population is highly exposed to urban violence, and overall conditional risk for PTSD was 11.1%. Violence prevention and enhancement of resilience should be part of public policies, and mental health sequelae of trauma should be better recognized and treated.

Psychotropic Drug Use in São Paulo, Brazil--An Epidemiological Survey.

OBJECTIVE: To estimate the prevalence of one month psychotropic drug use in São Paulo, Brazil, and to assess the gap treatment between the presence of mental disorders and psychotropic drug users. METHOD: A probabilistic sample of non-institutionalized individuals from the general population of São Paulo (n = 2336; turnout: 84.5%) who were 15 years or older were interviewed by a trained research staff, applying the Composite International Diagnostic Interview 2.1 (CIDI WHO) (depression, anxiety-phobia, OCD\PTSD, alcoholism sections), and an inventory investigating psychotropic drug use during the 12-month and one-month periods immediately preceding the interview. Logistic models were fitted to investigate associations between psychotropic drug use as well as socio-demographic and clinical variables. RESULTS: The one month prevalence of psychotropic drug use in São Paulo was 5.89%, the most commonly used drugs were antidepressants (3.15%) and tranquilizers (2.67%). A higher consumption of psychotropic drugs (overall, antidepressants and tranquilizers) was observed among women (OR:2.42), older individuals (OR:1.04), individuals with higher levels of formal education (1.06), and individuals with a family (OR:2.29) or personal history of mental illness (OR:3.27). The main psychotropic drug prescribers were psychiatrists (41%), followed by general practitioners (30%); 60% of psychotropic drugs were obtained through a government-run dispensing program. Most individuals who obtained a positive diagnosis on the CIDI 2.1 during the previous month were not using psychotropic medication (85%). Among individuals with a diagnosis of moderate to severe depression, 67.5% were not on any pharmacological treatment. CONCLUSION: There is a change in the type of psychotropic more often used in São Paulo, from benzodiazepines to antidepressants, this event is observed in different cultures. The prevalence of use is similar to other developing countries. Most of the patients presenting a psychiatric illness in the month prior to testing were not receiving any sort of psychiatric medication. This may be explained by a failure to identify cases in primary care, which could be improved (and access to treatment could be facilitated) if professionals received more specialized training in managing cases with mental health problems.

Electroconvulsive therapy for obsessive-compulsive disorder: a systematic review.

OBJECTIVE: Surgical therapies for treatment-refractory obsessive-compulsive disorder (OCD), such as deep brain stimulation or psychosurgery, remain unattainable for many patients. Despite the long-held view that electroconvulsive therapy (ECT) is an ineffective treatment for OCD, there is no systematic review to support or refute this claim, which is the basis of the current review. DATA SOURCES: A systematic search of MEDLINE, Web of Science, Scopus, and LILACS databases was conducted on December 22, 2013, using the terms obsessive-compulsive disorder and electroconvulsive therapy. Reference lists, specific journals, and clinical trial registries were also scrutinized. No date or language limitation was imposed on the search. STUDY SELECTION: After irrelevant and redundant records from the 500 identified titles were excluded, the 50 articles reporting the acute treatment effects of ECT in OCD and related constructs (involving a total of 279 patients) were analyzed for this study. DATA EXTRACTION: The relevant sociodemographic, clinical, and outcome data of individual cases were extracted. Data from individual cases were used to compare the characteristics of responders versus nonresponders to ECT. RESULTS: Most selected records were case reports/series; there were no randomized controlled trials. A positive response was reported in 60.4% of the 265 cases in which individual responses to ECT were available. ECT responders exhibited a significantly later onset of OCD symptoms (P = .003), were more frequently nondepressed (P = .009), more commonly reported being treated with ECT for severe OCD (P = .01), and received a fewer number of ECT sessions (P = .03). ECT responders were also less frequently previously treated with adequate trials of serotonin reuptake inhibitors (P = .05) and cognitive-behavioral therapy (P = .005). CONCLUSIONS: Although 60% of the reported cases reviewed exhibited some form of a positive response to ECT, it cannot be stated that this provides evidence that ECT is indeed effective for OCD.