Managing drug-induced psychosis.

Substance-induced psychosis is a secondary psychotic disorder resulting from drug abuse, characterized by one or more psychotic episodes. Drug-induced psychosis is expected to resolve after a 30-day period of sobriety, however, individuals with this condition are more likely to develop severe drug addiction. Compared to primary psychosis, participants with drug-induced psychosis exhibit poorer family history of psychotic diseases, higher insight, fewer positive and negative symptoms, more depressive symptoms, and greater anxiety. Substance-induced psychosis is strongly associated with the emergence of bipolar illness or schizophrenia spectrum disorder, with an increased chance of developing schizophrenia at a younger age. Episodes of self-harm after substance-induced psychosis are strongly linked to an elevated likelihood of developing schizophrenia or bipolar disorder. Effective treatment involves ruling out emergencies, investigating underlying causes, and addressing acute intoxication and withdrawal. Management includes dynamic assessment, intervention, and vigilant monitoring in cases of suicidal behaviour. Antipsychotics may be used for short term, with gradual discontinuation when a person is in a stable condition. Relapse prevention strategies, both medication and non-medication-based, are crucial in long-term management. Conversion rates to schizophrenia or bipolar disorder can be as high as one in three individuals, with cannabis users and those with early-onset substance abuse at the highest risk.

Brazilian Psychiatric Association Consensus on the physical structure and ideal team for psychiatric emergencies services.

INTRODUCTION: An integral part of Brazil's public health system, the psychiatric emergency service (PES) has been instrumental in improving qualified support for crisis situations of mental disorders, equitable, universally accessible, and humanized. The purpose of this article is to present a systematic review and consensus about the physical area and facilities, and ideal team qualified for psychiatric emergencies services on both Brazilian settings. METHODS: The authors conducted a literature search using electronic databases such as MEDLINE (PubMed), Scielo, the Cochrane Database, and documents from the WHO, the Brazilian Ministry of Health, and others deemed relevant by experts. A total of 6839 manuscripts were found, but only 46 were selected. The analysis of article content summarizes consensus statements using the Delphi method and a series of interactive versions to provide a final report. RESULTS: Changes to PES are evaluated considering various experiences and models. The authors highlighted that The Emergency Care Network (ECN) must be coordinated with qualified management, effective implementation of integration of all health equipment's and units. PES must have adequate infrastructure; qualified staff, including a psychiatrist; sufficient consultation and observational spaces; tools and resources for differential diagnosis; training for all staff members; and communication with the health care network to facilitate referrals following patient discharge are all necessary. CONCLUSION: These standardized models need to be available to public health managers so that they can guide the installation of new services and adjust the existing ones, always looking for improvement. The authors propose requirements for PES as a model to be passed over.

Translation, cross-cultural adaptation, and validation of the Behavioral Activity Rating Scale (BARS) for the Brazilian population.

INTRODUCTION: Few instruments are available in Brazil to evaluate psychomotor activity in psychiatric emergency, clinical, and research settings. This study aimed to perform a cross-cultural adaptation of the Behavioral Activity Rating Scale (BARS) into Brazilian Portuguese and assess the adapted scale's psychometric properties. METHOD: An expert consensus committee conducted a translation and back-translation of the original scale, resulting in the BARS-BR. Four pairs of physicians administered the BARS-BR and the Sedation-Agitation Scale (SAS) to patients in a hospital psychiatry emergency room and patients in the hospital's psychiatric wards. The BARS-BR was compared to the SAS to assess concurrent validity and internal consistency was evaluated with the Bland-Altman technique. RESULTS: In the emergency room, the correlation coefficients between the first and second assessments were rho = 0.997 and rho = 1.0, respectively. In the hospital wards, the correlation coefficient between the pair of evaluators was rho = 0.951. There were strong correlations between the BARS-BR score of the first examiner and the SAS score of the second examiner (rho = 0.903) and between the SAS score of the first examiner and the BARS-BR score of the second examiner (rho = 0.893). CONCLUSION: The BARS-BR showed good psychometric properties, and we recommend its use because it constitutes an easy method for assessment of changes in psychomotor activity. Further studies are suggested to evaluate adoption and comprehension of the BARS-BR scale by all classes of healthcare professionals.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 3. Suicide prevention hotlines.

Crisis hotlines are direct communication systems, usually telephone-based, set up to prevent suicide. However, few studies have evaluated their effectiveness. The present study aims to perform a systematic review, using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework, of the effectiveness of interventions through direct communication systems to reduce the number of suicides or suicide attempts. We searched the MEDLINE, Cochrane, SciELO, and ClinicaTrials.gov databases, and used the 2011 Oxford Centre for Evidence-Based Medicine Levels of Evidence classification. The literature search yielded 267 studies, of which 35 fulfilled the selection criteria. Although significant heterogeneity was found among studies, there is evidence that direct telephone interventions are effective when included in broader preventive protocols and provided by trained staff. Despite the limitations, which included heterogeneity of samples, designs, and outcome measures, we were able to design a protocol for the use of remote services to prevent suicide and suicide attempts. A hotline or similar system could be an effective intervention for broader suicide prevention programs. However, further research is necessary to specify which protocol components are key to enhance effectiveness.

Brazilian Psychiatric Association guidelines on the integration of spirituality into mental health clinical practice: Part 1. Spiritual history and differential diagnosis.

OBJECTIVES: To present evidence-based guidelines for clinical practice regarding religiosity and spirituality in mental health care in Brazil. METHODS: A systematic review was conducted to identify potentially eligible articles indexed in the PubMed, PsycINFO, SciELO, LILACS, and Cochrane databases. A summary of recommendations and their levels of evidence was produced in accordance with Oxford Centre for Evidence-Based Medicine guidelines. RESULTS: The systematic review identified 6,609 articles, 41 of which satisfied all inclusion criteria. Taking a spiritual history was found to be an essential part of a compassionate and culturally sensitive approach to care. It represents a way of obtaining relevant information about the patient's religiosity/spirituality, potential conflicts that could impact treatment adherence, and improve patient satisfaction. Consistent evidence shows that reported perceptual experiences are unreliable for differentiating between anomalous experiences and psychopathology. Negative symptoms, cognitive and behavioral disorganization, and functional impairment are more helpful for distinguishing pathological and non-pathological anomalous experiences. CONCLUSION: Considering the importance of religiosity/spirituality for many patients, a spiritual history should be routinely included in mental health care. Anomalous experiences are highly prevalent, requiring a sensitive and evidence-based approach to differential diagnosis.

Brazilian Psychiatric Association guidelines for the treatment of generalized anxiety disorder (GAD). Pharmacological and Psychotherapy approach. Perspectives.

OBJECTIVE: To combine elements of a systematic review and critical review to produce best evidence synthesis for the treatament of GAD. METHOD: There was included systematic reviews, metanalysis, and randomized controlled trials. Descriptor used was "generalized anxiety disorder", resulting in 4860 articles and 7 other studies, of which 59 were selected. RESULTS: Antidepressants and benzodiazepines are indicated, as well as pregabalin. From, atypical antipsychotics quetiapine has been studied. Cognitive behavior therapy (third wave of behavioral and cognitive therapies) as well as individual CBT proven to be effective. CONCLUSION: There is extensive literature on many effective treatments for GAD. The present work summarizes the therapeutic possibilities, emphasizing those available in the Brazil. Further studies are still needed to compare other available medications, to assess psychotherapies in more depth, new treatments and specially to assess the ideal time for maintaining therapy.

Can medical residency keep young specialists in the place where they graduate? Cross-sectional and exploratory study of the first seven years after implementation of medical residency programs in the State of Tocantins, Brazil.

BACKGROUND: New medical schools and new medical residencies in Brazil, mainly in its interior, were opened under the justification of collaborating towards distribution of these healthcare professionals and specialist doctors across the national territory. However, this proposal did not guarantee that medical practitioners would become established in the place where they graduated and specialized. OBJECTIVE: To calculate, through interviews, how many specialists who graduated in the state of Tocantins stayed there after finishing their medical residency; and to analyze the factors that made them stay or leave the place. DESIGN AND SETTING: Cross-sectional exploratory study conducted at a Brazilian federal public higher education institution. METHODS: All graduates from medical residencies in Tocantins, who graduated between 2013 and 2019, were contacted by telephone and, after obtaining consent, an interview was conducted. The interviews took place between June 2020 and January 2021. RESULTS: The permanence of medical residency graduates in the state increased from 50% in an earlier study to 55.8% in the current study, thus showing a situation of stability. In addition, we detected some reasons for staying or not. In a multivariate analysis, only working in the state capital was related to staying in the state of Tocantins, showing a 5.6 times greater chance. CONCLUSIONS: The percentage of those who remained was just over 50%, even some years after implementation of the first programs. Most specialists remained working for the state health department, with a smaller proportion in municipal health departments, and were concentrated in the state capital.

Psychiatric emergency units in Brazil: a cross-sectional study.

OBJECTIVES: This study aimed to identify the infrastructure (e.g., availability, resources, and staff), basic metrics, and problems (e.g., network, overcrowding, resources, and infrastructure) of the psychiatric emergency services in Brazil. METHODS: This is a cross-sectional study assessing psychiatric services (n=29) listed by the Brazilian Psychiatric Association in 2019. RESULTS: Almost all the units reported 24 h/7-day availability having psychiatrists, nurses, and social workers, with 8.8 (SE=2.2) and 2.8 (SE=0.3) consultations and hospitalizations per day, respectively. Separated room for contention was reported by the minority of the services (38%). The most commonly reported problems were insufficient structure for child/adolescent care (83%), increasing patient demand (72%), housing referral for homeless (72%), excessive prescription demand (69%), short-term room overcrowding (59%), court orders for inpatient treatment (59%), lack of vacancies for inpatients hospitalization (59%), and referral to primary care (56%). CONCLUSIONS: Similar to the United States, the Brazilian psychiatric emergency units are decreasing and encompass the shortcomings of the Brazilian mental health care network.

Longitudinal invariance and validity of the Impact of Event Scale-Revised under COVID-19 pandemic in a Brazilian sample.

Although the Impact Event Scale-Revised is widely used, its factor structure is still controversial. In addition, its longitudinal measurement invariance (LMI) remains uninvestigated. In this sense, we carried out three studies to investigate its psychometric properties. In Study 1, we evaluated the factorial structure of the scale comparing the different models existing in the literature in Brazilian samples who responded to the instrument during the COVID-19 pandemic. In Study 2, we provide support for a five-factor model throughout convergent validity with psychological distress and sleep problems, and criterion validity between people with diagnostic of mental disorders. Finally, we evaluated the LMI over a 6-month interval. The results indicated that the five-factor model has excellent goodness of fit and holds strict longitudinal invariance. Additionally, internal consistency and stability coefficients indicate that the scale is appropriate to measure posttraumatic stress symptomatology) in nonclinical samples across multiple assessments. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Social Determinants in Self-Protective Behavior Related to COVID-19: Association Rule-Mining Study.

BACKGROUND: Human behavior is crucial in health outcomes. Particularly, individual behavior is a determinant of the success of measures to overcome critical conditions, such as a pandemic. In addition to intrinsic public health challenges associated with COVID-19, in many countries, some individuals decided not to get vaccinated, streets were crowded, parties were happening, and businesses struggling to survive were partially open, despite lockdown or stay-at-home instructions. These behaviors contrast with the instructions for potential benefits associated with social distancing, use of masks, and vaccination to manage collective and individual risks. OBJECTIVE: Considering that human behavior is a result of individuals' social and economic conditions, we investigated the social and working characteristics associated with reports of appropriate protective behavior in Brazil. METHODS: We analyzed data from a large web survey of individuals reporting their behavior during the pandemic. We selected 3 common self-care measures: use of protective masks, distancing by at least 1 m when out of the house, and handwashing or use of alcohol, combined with assessment of the social context of respondents. We measured the frequency of the use of these self-protective measures. Using a frequent pattern-mining perspective, we generated association rules from a set of answers to questions that co-occur with at least a given frequency, identifying the pattern of characteristics of the groups divided according to protective behavior reports. RESULTS: The rationale was to identify a pool of working and social characteristics that might have better adhesion to behaviors and self-care measures, showing these are more socially determined than previously thought. We identified common patterns of socioeconomic and working determinants of compliance with protective self-care measures. Data mining showed that social determinants might be important to shape behavior in different stages of the pandemic. CONCLUSIONS: Identification of context determinants might be helpful to identify unexpected facilitators and constraints to fully follow public policies. The context of diseases contributes to psychological and physical health outcomes, and context understanding might change the approach to a disease. Hidden social determinants might change protective behavior, and social determinants of protective behavior related to COVID-19 are related to work and economic conditions. TRIAL REGISTRATION: Not applicable.

Brazilian Psychiatric Association Consensus for the Management of Acute Intoxication. General management and specific interventions for drugs of abuse.

OBJECTIVE: To present the Brazilian Psychiatric Association's Consensus for the Management of Acute Intoxication. METHODS: A group of experts selected by the Brazilian Psychiatric Association searched for articles in the MEDLINE (by PubMed) and Cochrane Database, limited to human studies and acute intoxication. Groups reviewed these materials for appropriateness to the topic and the quality of the work. To perform a table of agreed recommendations at the end of the systematic review, a survey using the Delphi method was conducted. Three survey rounds were conducted to develop a consensus. RESULTS: Support for intoxication may start with Initial Management: Resuscitation/Life Support/Differential Diagnosis. For that, the group proposed these orders of assessment: A (airway), B (breathing), C (circulation), D.1. (disability), D.2. (differential diagnosis), D.3. (decontamination), D.4. (drug antidotes), E (enhanced elimination). Then, the group of experts presented specific interventions for the main drugs of abuse. CONCLUSIONS: The approach to intoxication with drugs of abuse is complex and requires systematic protocols. The group of experts suggested the adoption of the classic use in welcoming the patient of the A-B-C-D-E technique with constant investigation of this patient until reaching a specific conduct and with the support to remit the picture. The group of experts believes that this document, at this time, can help psychiatric, general, and emergency doctors deal with psychiatric emergency episodes due to acute intoxication.

The Management of Psychiatric Emergencies in Situations of Public Calamity.

The prevalence of mental health problems in the general population during a public calamity is high. In calamities, the number of patients who present with mental disorder outbreaks or crises may increase, but the necessary support systems to help them may be impaired if they have not been planned for. Although there are several models for addressing psychiatric emergencies, the general rules are the same, especially when it comes to making these services easily available to the affected population. In this article, we seek to review and present recommendations for the management of psychiatric emergencies in situations of public calamity, including disasters, physical and medical catastrophes, epidemics, and pandemics.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 1. Risk factors, protective factors, and assessment.

Suicide is a global public health problem that causes the loss of more than 800,000 lives each year, principally among young people. In Brazil, the average mortality rate attributable to suicide is approximately 5.23 per 100,000 population. Although many guidelines have been published for the management of suicidal behavior, to date, there are no recent guidelines based on the principles of evidence-based medicine that apply to the reality of suicide in Brazil. The objective of this work is to provide key guidelines for managing patients with suicidal behavior in Brazil. This project involved 11 Brazilian psychiatry professionals selected by the Psychiatric Emergencies Committee (Comissão de Emergências Psiquiátricas) of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. For the development of these guidelines, 79 articles were reviewed (from 5,362 initially collected and 755 abstracts). In this review, we present definitions, risk and protective factors, assessments, and an introduction to the Safety Plan. Systematic review registry number: CRD42020206517.

Brazilian Psychiatric Association guidelines for the management of suicidal behavior. Part 2. Screening, intervention, and prevention.

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eighty-five articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention. Systematic review registry number: CRD42020206517.

The Impact of Mental Illness Stigma on Psychiatric Emergencies.

Psychiatric emergencies are severe behavioral changes secondary to worsening mental illness. Such situations present a risk to the patient and other people, so they need immediate therapeutic intervention. They are associated with feelings of fear, anger, prejudice, and even exclusion. The attitudes of professionals and factors related to the workplace culture in health can help to perpetuate stereotypes and interfere with the quality of care. Stigma has undesirable consequences in patients with mental disorders. Certain measures can reduce stigma and provide a more dignified way for patients to recover from the crisis. This article aims to discuss the causes of stigma, ways of dealing with it, and achievements that have been made in psychiatric emergency care settings.

Dating Applications, Sexual Behaviors, and Attitudes of College Students in Brazil's Legal Amazon.

Although dating applications (apps) have become popular among young adults, there is a dearth of information regarding the sexual health implications among Brazilian college students. This study examined risky sexual behavior and attitudes of dating app users, based on their sex in Brazil's Legal Amazon. Three hundred and fifty-nine students reported their sociodemographic data, dating app use, and sexual behaviors and attitudes through self-administered questionnaires. Bivariate analyses and analysis of variance (ANOVA) with Bonferroni post-hoc tests were performed. Dating app use was reported by 238 (66.3%) subjects, most of whom had an encounter and sex with a casual partner. Women frequently requested condom use. Trust in one's partner or having repeated encounters were the main reasons for engaging in risky sexual behavior. Men had a greater number of sexual partners and less protective attitudes. Sexual health awareness by apps was not reported by 97% of women, and most of them were not tested for sexually transmitted infections. A positive attitude toward sexual health was not a predictor of safe sex. Important similarities and differences regarding risky sexual behaviors and attitudes were observed between the sexes, many of which correlated with increased sexual vulnerability during the sexual encounters arranged through the dating apps. This cross-sectional study supports efforts on sexual health promotion and sexual education implementation in the face of growing usage of apps among young adults for sexual matters.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach.

OBJECTIVE: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. METHODS: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. RESULTS: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. CONCLUSION: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. SYSTEMATIC REVIEW REGISTRY NUMBER: CRD42017054440.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach.

OBJECTIVE: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil. METHODS: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. RESULTS: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree. CONCLUSION: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint. SYSTEMATIC REVIEW REGISTRY NUMBER: CRD42017054440.