The posttraumatic stress disorder project in Brazil: neuropsychological, structural and molecular neuroimaging studies in victims of urban violence.

BACKGROUND: Life trauma is highly prevalent in the general population and posttraumatic stress disorder is among the most prevalent psychiatric consequences of trauma exposure. Brazil has a unique environment to conduct translational research about psychological trauma and posttraumatic stress disorder, since urban violence became a Brazilian phenomenon, being particularly related to the rapid population growth of its cities. This research involves three case-control studies: a neuropsychological, a structural neuroimaging and a molecular neuroimaging study, each focusing on different objectives but providing complementary information. First, it aims to examine cognitive functioning of PTSD subjects and its relationships with symptomatology. The second objective is to evaluate neurostructural integrity of orbitofrontal cortex and hippocampus in PTSD subjects. The third aim is to evaluate if patients with PTSD have decreased dopamine transporter density in the basal ganglia as compared to resilient controls subjects. This paper shows the research rationale and design for these three case-control studies. METHODS AND DESIGN: Cases and controls will be identified through an epidemiologic survey conducted in the city of São Paulo. Subjects exposed to traumatic life experiences resulting in posttraumatic stress disorder (cases) will be compared to resilient victims of traumatic life experiences without PTSD (controls) aiming to identify biological variables that might protect or predispose to PTSD. In the neuropsychological case-control study, 100 patients with PTSD, will be compared with 100 victims of trauma without posttraumatic stress disorder, age- and sex-matched controls. Similarly, 50 cases and 50 controls will be enrolled for the structural study and 25 cases and 25 controls in the functional neuroimaging study. All individuals from the three studies will complete psychometrics and a structured clinical interview (the Structured Clinical Interview for DSM-IV and the Clinician-Administered PTSD Scale, Beck Anxiety Inventory, Beck Depression Inventory, Global Assessment of Function, The Social Adjustment Scale, Medical Outcomes Study 36-Item Short-Form Health Survey, Early Trauma Inventory, Clinical global Impressions, and Peritraumatic Dissociative Experiences Questionnaire). A broad neuropsychological battery will be administered for all participants of the neuropsychological study. Magnetic resonance scans will be performed to acquire structural neuroimaging data. Single photon emission computerized tomography with [(99m)Tc]-TRODAT-1 brain scans will be performed to evaluate dopamine transporters. DISCUSSION: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting translational research in the field of trauma and posttraumatic stress disorder.

Use of mental health services by community-resident adults with DSM-IV anxiety and mood disorders in a violence-prone area: São Paulo, Brazil.

BACKGROUND: While under-use of mental health services by adults with anxiety and/or depression is well established, use in a violence-prone area, and as a function of diagnosis and personality characteristics such resilience, is little known. We examine the sociodemographic and personality characteristics (specifically resilience), associated with use of mental health services in a violence-prone city by those with anxiety, depression, and their comorbidity. METHODS: The structured Composite International Diagnostic Interview was used to identify 12-month DSM-IV- and ICD-10-defined anxiety and depression in a cross-sectional, representative, community-resident sample age 15-75y (N = 2536) in São Paulo, Brazil, and their use of mental health services. Resilience was determined by the Wagnild and Young scale. Analyses, using weighted, design-corrected statistical tests, included frequency measures and multivariable logistic regression. RESULTS: Mental health services were used by 10% with only anxiety, 22% with only depression, and 34% with comorbidity, with odds of use in controlled analyses doubling from anxiety to depression to comorbidity. Use was significantly higher among those who were white, older (age >30 years, with substantial social support, low resilience, living in low homicide rate areas; use was not affected by experience of traumatic events. Psychiatrists, general practitioners, and psychologists were the primary providers. LIMITATIONS: Cross-sectional design CONCLUSIONS: Contrary to expectation, use was greater among residents of lower homicide areas, and was not associated with personal traumatic experience. This may reflect increased immunity to violence in higher homicidal rate areas, lower resilience, and poorer access to services. Increased access to mental health services is needed.

12-month prevalence and concomitants of DSM-IV depression and anxiety disorders in two violence-prone cities in Brazil.

BACKGROUND: Estimating 12-month prevalence of depression, anxiety, and comorbid anxiety/depression in noninstitutionalized adults (age 15-75) in two violence-prone cities. METHODS: The Composite International Diagnostic Interview v2.1 (Portuguese), administered in population-representative surveys (age 15-75) in São Paulo (N = 2536) and Rio de Janeiro (N = 1208), yielded 12-month prevalence of violent events experienced, and DSM-IV diagnoses of depression and anxiety, which were classified into mutually exclusive groups: 1) no anxiety/depression; 2) anxiety only; 3) depression only; 4) comorbid anxiety/depression. Weighted analyses estimated 12-month prevalence, multinomial logistic regression compared the demographic characteristics of the diagnosis groups, and association with experienced violence. RESULTS: Twelve-month prevalence of anxiety alone, depression alone, and comorbid anxiety/depression was 12.7% (of whom 24.9% were also depressed), 4.9% (of whom 46.2% had anxiety), and 4.2% respectively for São Paulo; and 12.1% (18.2% of whom were depressed), 4.6% (37.0% with anxiety), and 2.7% respectively for Rio de Janeiro. All conditions were approximately twice as prevalent in women than in men in both cities. In São Paulo, comorbidity was associated with age under 60, depression alone was more prevalent among 30-59 year olds, but in 23-29 year-olds in Rio de Janeiro. Exposure to violence increased the odds of anxiety, depression, and their comorbidity. With rare exception, marital status, education, and race/ethnicity were not associated with anxiety, depression, or their comorbidity. LIMITATIONS: Cross-sectional design. CONCLUSIONS: Prevalence rates for all conditions were high, and particularly associated with exposure to violence. Means to ameliorate violence, and its mental health effects, particularly for women, are needed.

The joint structure of major depression, anxiety disorders, and trait negative affect.

BACKGROUND: Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil. METHODS: The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling. RESULTS: Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect. CONCLUSIONS: This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology.

The joint structure of major depression, anxiety disorders, and trait negative affect

Background: Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil. Methods: The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling. Results: Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect. Conclusions: This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology. .