Nuevas tecnologías y atención en Salud Mental. Encuesta a psiquiatras y psicólogos de Argentina sobre el uso del WhatsApp.

OBJETIVOS: La comunicación entre pacientes y profesionales de la salud mental mediante plataformas de mensa- jería en el intervalo entre encuentros presenciales o virtuales se convirtió en una modalidad de teleconsulta asincrónica (TA) cuya utilidad y efecto en la carga de trabajo de los profesionales de salud mental no se han explorado. Método: Profesionales del campo de la salud mental que trabajan en Argentina fueron invitados a responder a una encuesta que exploraba la intensidad y utilidad de la TA, y la sobrecarga resultante. RESULTADOS: Se recibieron un total de 527 respuestas de profesionales que trabajan en todo el país. El 69 % de los encuestados mensajes con un promedio de 1-10 pacientes/día y el 31 % con más de 10 pacientes/día; el 75 % respondió mensajes por teléfono móvil los fines de semana. Mientras que el 68 % calificó estas interacciones como positivas para  el seguimiento clínico, el 47 % las consideró una fuente de sobrecarga laboral. CONCLUSIONES: La adopción generalizada de la TA puede requerir una autorregulación adicional por parte de los profesionales y un seguimiento regular de los niveles de sobrecarga (especialmente, entre los psiquiatras) para que su práctica clínica diaria sea eficiente y sostenible.

Multidimensional evaluation of a 12-month intensive outpatient program for the treatment of substance use disorder. Experience in Argentina / Evaluación multidimensional de un programa de tratamiento ambulatorio intensivo de 12 meses para el trastorno por uso de sustancias. Experiencia en Argentina.

OBJECTIVE: The purpose of this study was to asess the efficacy of an intensive outpatient treatment (IOT) for substance use disorder (SUD) using a multidimensional approach. METHODS: All the patients consecutively admitted to a private institution between May 2019 and May 2020 were invited to participate in the study. The program consisted in a 12-month set of psychosocial, medical and recreative interventions requiring an attendance of at least 9 hours per week. Efficacy was evaluated at admission and every three months by the Addiction Severity Index (ASI). Quality of life was evaluated at admission and at the end of the treatment by the WHOQOL-Bref questionnaire. A comparison of parameters obtained at admission between the group that completed and the one that abandonned the treatment was also performed to detect potential predictors of early dropout. Six months after the end of the treatment, the participants were contacted in order to repeat an evaluation through the ASI and the WHOQOL-Bref scales. RESULTS: 41 participants (73% male, age 42.8 ± 16 years) were included. 14 participants dropped out at a median time of 88 days. Among those who completed the treatment improvements were observed in different clinical dimensions: in alcohol and drug consumption (3 months), in medical problems (6 months), in family/social relationships (9 months), in psychological scores (12 months) and in the four dimensions of WHOQOL-Bref. No changes were observed in legal problems and in the employment status. Only legal problems and family/social relationships at admission were significantly different among patients who completed versus those who dropped-out. Six months after discharge, no differences in WHOQOL-Bref scores were observed in the 15 participants who could be located and accepted the assessment. A little but statistically significant worsening was observed in the psychological problems dimension of the ASI in post-discharge follow-up. The rest of the ASI dimensions remained unchanged 6 months after concluding the treatment. CONCLUSION: This is one of the few studies performed in a latinamerican setting assessing the efficacy of a long-term IOT for SUD. It confirms previous works from developed countries, showing the potential benefits of IOTs implementation in our region.

OBJETIVO: Evaluar la eficacia de un tratamiento ambulatorio intensivo (TAI) para el trastorno por uso de sustancias (TUS) utilizando un enfoque multidimensional. Métodos: Se incluyeron todos los pacientes admitidos consecutivamente en una institución privada entre mayo de 2019 y mayo de 2020. El programa duró 12 meses y consistió en un conjunto de intervenciones médicas, psicosociales y recreativas, con una intensidad ≥ 9 horas/semana. La eficacia fue evaluada comparando los puntajes en el Índice de Severidad de Adicción (ASI) a lo largo del programa y en el cuestionario WHOQOL-Bref al inicio y al finalizar. En 15 pacientes se realizó una nueva medición seis meses después de concluido el tratamiento. MÉTODOS: Se incluyeron todos los pacientes admitidos consecutivamente en una institución privada entre mayo de 2019 y mayo de 2020. El programa duró 12 meses y consistió en un conjunto de intervenciones médicas, psicosociales y recreativas, con una intensidad ≥ 9 horas/semana. La eficacia fue evaluada comparando los puntajes en el Índice de Severidad de Adicción (ASI) a lo largo del programa y en el cuestionario WHOQOL-Bref al inicio y al finalizar. En 15 pacientes se realizó una nueva medición seis meses después de concluido el tratamiento. RESULTADOS: Se incluyeron 41 participantes (73% hombres, edad 42,8 ± 16 años). 14 participantes abandonaron (media 88 días). En los participantes que completaron el tratamiento, se observaron mejoras en los índices de alcohol y drogas (a los 3 meses), en problemas médicos (a los 6 meses), en las relaciones sociales y familiares (a los 9 meses) y en problemas psicológicos (a los 12 meses) así como  en las cuatro dimensiones del WHOQOL-Bref. Estas mejoras persistieron en la evaluación 6 meses post-alta cuando sólo un empeoramiento leve en la dimensión de problemas psicológicos del ASI fue objetivado. Conclusión: Este es uno de los pocos estudios realizados en un ámbito latinoamericano que evalúa la eficacia de un TAI para el TUS. Confirma trabajos previos de países desarrollados, mostrando los beneficios potenciales de la implementación de TAIs en nuestra región. CONCLUSIÓN: Este es uno de los pocos estudios realizados en un ámbito latinoamericano que evalúa la eficacia de un TAI para el TUS. Confirma trabajos previos de países desarrollados, mostrando los beneficios potenciales de la implementación de TAIs en nuestra región.

[Practical notes on locating and critically reading scientific bibliography to guide clinical decisions, with a focus on quantitative research]. / Apuntes prácticos para localizar y leer críticamente bibliografía científica que oriente decisiones clínicas con foco en la investigación cuantitativa.

In clinical practice it is increasingly imperative to obtain updated information for decision making. For health professionals, it is of great value to collect the experience that other workers in the disciplinary field have synthesized in the form of articles, reviews or different types of reports. Moreover, having tools that allow weighing the internal and external validity of the publications found, provides skills that today are essential for a clinical practice that guarantees patients the best standards of care. These notes are intended to guide readers in obtaining and assessing the information available for reasoned decision making.

Day hospital treatment for people with severe mental illness according to users' perspectives: what helps and what hinders recovery?

BACKGROUND: Scarce information is available about how users experience treatment at mental health day hospitals, particularly in South America. AIMS: To explore users' perspectives about elements of day hospital treatment that facilitate or hinder the recovery process in a mental health facility in Buenos Aires, Argentina. METHODS: Semi-structured individual interviews (n = 8) and focus groups (n = 4) were carried out with a convenience sample of users of a mental health day hospital program based on a formulation, testing and redevelopment of propositions approach. Results were analyzed through grounded theory techniques. RESULTS: Categories indicating recovery were: starting to do things, being able to see themselves from a new perspective, mood improvement and changes in interpersonal relationships. Aspects facilitating recovery were: activities organized by the facility, the group approach, the care provided by facility workers and the physical environment. Hindering aspects were: heterogeneity of users in terms of age, severity, diagnosis and being underestimated by staff. CONCLUSIONS: Being active again was considered to be the main recovery indicator in this cultural context and participating in activities led by skilled facilitators was the most beneficial factor of the program according to the users.

[Association between mental illness, obesity and metabolic syndrome. Effect of the treatment with psychotropic drugs]. / Asociación entre enfermedad mental, obesidad y síndrome metabólico. Efecto de los tratamientos psicofarmacológicos.

Persons with mental disorders present higher morbimortality than that observed in general population. Among the factors contributing with this situation we can mention an increase in the incidence of obesity and metabolic syndrome, with their burden of cardiovascular and cancer risks. This review summarizes the evidence about the comorbid presence of schizophrenia, unipolar depression and bipolar disorder on one side and metabolic syndrome or obesity on the other. We also review the different causes of such comorbidity, in particular the adverse effects of psychotropic drugs, diverse biological factors predisposing to the increase in body weight and the measures that can be taken in order to attenuate or prevent metabolic disease in persons affected by mental illness.

Body mass index, waist circumference, insulin, and leptin plasma levels differentiate between clozapine-responsive and clozapine-resistant schizophrenia.

BACKGROUND: Between 25% and 50% of patients suffering from treatment-resistant schizophrenia fail to achieve a clinical response with clozapine. The rapid identification and treatment of this subgroup of patients represents a challenge for healthcare practice. AIMS: To evaluate the relationship between metabolic alterations and the clinical response to clozapine. METHODS: A multicenter, observational, case-control study was performed. Patients diagnosed with schizophrenia treated with clozapine were eligible (minimum dose 400 mg/d for at least 8 weeks and/or clozapine plasma levels ⩾ 350 µg/mL). According to the Positive and Negative Syndrome Scale (PANSS) total score, patients were classified as clozapine-responsive (CR) (<80 points) or clozapine non-responsive (CNR) (⩾80 points). Groups were compared based on demographic and treatment-related characteristics, together with body mass index (BMI), waist circumference, insulin, leptin, and C-reactive protein plasma levels. Plasma levels of clozapine and its main metabolite, nor-clozapine, were measured in all the participants. In addition, the potential relationship between PANSS scores and leptin or insulin plasma levels was assessed. RESULTS: A total of 46 patients were included: 25 CR and 21 CNR. BMI and waist circumference, fasting insulin and leptin plasma levels were lower in the CNR group, while C-reactive protein was not different. Moreover, significant negative correlations were observed between PANSS positive and general psychopathology subscores, on one hand, and insulin and leptin plasma levels, on the other hand, as well as between PANSS negative subscores and leptin plasma levels. CONCLUSIONS: Our results suggest that the lack of metabolic effect induced by clozapine is associated with the lack of clinical response.

[Dysthimia or chronic depression: what do we know about its pharmacological treatment?]. / Distimia o depresión crónica: ¿qué sabemos acerca de su tratamiento farmacológico?

The term dysthymia is applied to a clinical picture characterized by depressive feelings of low intensity and chronic evolution. Psychiatric nosology includes it among the mood disorders or among neurosis and personality disorders. This ambiguity has empirical consequences, since bibliography examining the efficacy of the different treatments is relatively scarce, in particular if we consider the incidence of the dysthymic disorder, that rounds 3% of general population. In this work the history of the nosology of dysthimia, the efficacy of pharmacological approaches and a brief mention about the efficacy of adding psychotherapy are summarized. Current literature indicates that antidepressants, independently of the group they form part of, are better than placebo, that maintenance treatment should be recommended and that psychotherapy could bring an additional benefit.

[Physiopathogeny in psychiatry: discovery, construction or discovery plus construction? The "case" of depression]. / Fisiopatogenia En Psiquiatría: ¿descubrimiento, construcción o descubrimiento + construcción? El "caso" de la depresión.

This work summarizes the efforts made in the last twenty years towards the discovery of the physiopathogeny of mental diseases. It takes the "case" of major depression and reviews the different theories proposed to explain its physiopathogeny beginning with the role of excitatory aminoacids, glucocorticoids and trophic neurofactors in the '90s, the neurogenesis at the beginning of '00s and the genetics, the epigenetics and the research on neural networks in the last years. Result of these scientific efforts seem to be a construction which has at the same time the strength of the evidences employed in its building and the weakness that emerges from the reductionism necessary to obtain them.

Comparison between HET-CAM protocols and a product use clinical study for eye irritation evaluation of personal care products including cosmetics according to their surfactant composition.

The hen's egg test on chorioallantoic membrane (HET-CAM) is one of the most frequently used alternative tests for prediction of ocular irritation of cosmetic products. There are different HET-CAM protocols widely accepted, but there is no information about which of the protocols better correlates with the results obtained in product use clinical study under the conditions of use. Two Fix Time Methods (FTM) -Lüepke and the ICCVAM guideline - and two Reaction Time Methods (RTM) -ECVAM DBALM Prot. No. 47 and No. 96- were employed to test 18 cosmetic products. Simultaneously, they were evaluated by an ophthalmological clinical test. A unified classification system was used, and products were classified into four irritation levels: non-irritant, weak, moderate and severe irritant. The duration of use (rinse-off or leave-on), and the concentration and type of surfactants were taken into account in the analysis. All the products that were classified as non-irritant by any HET-CAM protocols were also safe in the product use clinical study. The product that was found to be non-safe in the product use clinical evaluation was also unsuitable by most of the HET-CAM protocols. These results were employed to develop an algorithm that allows selecting the appropriate HET-CAM protocol for each type of product to be tested.

[How do Argentinean psychiatrists treat bipolar depression?]. / ¿Cómo tratan los psiquiatras argentinos la depresión bipolar?

We show the results of a survey on bipolar depression treatment using a sample of 359 argentine psychiatrists in the context of The National Psychiatry Congress that took place in the City of Buenos Aires, between September 26th and 29th, 2007. The objective was to study the attendant psychiatrists' prescribing habits in the treatment of bipolar depression. The discussion is based on the comparison between the answers and the recommendations taken from the main consensus, guidelines and from articles published by experts. The differences found point to the distance often present between guidelines and expert consensus series (based on patients meeting the strict criteria used in randomized controlled studies) on one hand, and a clinician's everyday real world practice, on the other hand.

[From symptomatic stability to functional recovery in the pharmacological treatment of schizophrenia and unipolar depression]. / De la estabilización sintomática a la recuperación funcional en el tratamiento farmacológico de la Esquizofrenia y la Depresión Unipolar.

This work summarizes the efficacy of pharmacotherapy in the chronic course of schizophrenia and unipolar depresion. It is aimed to answer three questions: does it cure these diseases? Does it exert any significant effect on the symptomatic presentation of the disorders? Which is its action on the social dysfunction provoked by schizophrenia or depression? A conceptual analysis of available bibliography was performed. It could be concluded that antypsychotics improve the symptomatic course of schizophrenia, although their efficacy is limited, and that these drugs does not act on the social dysfunction provoked by the disease. With respect to depression, it could be concluded that a significant proportion of patients remain symptomatic despite receiveng adequate treatments. No data about efficacy of pharmacotherapy on the dysfunction resultant from unipolar depression is available.

Maintenance treatment with fluoxetine is necessary to sustain normal levels of synaptic markers in an experimental model of depression: correlation with behavioral response.

Dysfunction of hippocampal plasticity has been proposed to play a critical role in the pathophysiology of depression. However, antidepressant drug effects on synaptic plasticity and cytoskeletal remodeling remain controversial. The aim of the present study was to evaluate in animals exposed to the learned helplessness (LH) paradigm, an accepted experimental model of depression, the effect of chronic treatment with fluoxetine (FLX) on synaptic and cytoskeletal proteins known to undergo plastic changes. Synaptophysin (SYN), postsynaptic density 95 (PSD-95), axon growth-associated protein 43 (GAP-43), and cytoskeletal proteins (intermediate neurofilaments and MAP-2) were studied in the hippocampus by immunohistochemistry. Whereas LH animals treated 21 days with saline (LH-S group) displayed diminished SYN and PSD-95 immunostainings in the CA3 but not in the DG, chronic treatment with FLX not only reversed the despaired behavior induced by exposure to LH paradigm, but also fully recovered SYN and PSD-95 labeling to control values. Similar results were obtained for the axonal remodeling marker GAP-43. FLX treatment did not modify either the decreased light neurofilament subunit (NFL) observed in the hippocampus of LH animals or any other cytoskeletal protein studied. When FLX treatment was withdrawn for 90 days in those LH-FLX animals in which reversion of despair had been observed at day 25, recurrence of despaired behavior was found accompanied by decreased SYN, PSD-95, and NFL labelings. Results indicate that the synapse remodeling induced by FLX in the CA3 region could underlie its behavioral efficacy despite the absence of cytoskeletal remodeling and that the stability of synaptic changes would depend on the continuous administration of the drug.

[Psychopharmacological drugs and ethiopathogenic theories in psychiatry. From discovery context to epistemological obstacle]. / Psicofármacos y teorías etiopatogénicas en Psiquiatría. Del contexto de descubrimiento al obstáculo epistemológico.

This work postulates the thesis that the development of the contemporary psychopharmacology, which began with the chemical changes imposed to molecules with antihistaminergic properties, modelled the current ethiopatogenic theories of mental diseases. The development of chlorpromazine and imipramine was coincident with the beginning of the research about neurotransmission. This coincidence contributed for the construction of the dopaminergic theory of schizophrenia and in the monoaminergic theory of depression. Limitations of the effectivity of current drugs, as observed in the trials CATIE and STAR-D may justify a change of perspective in the search for new molecular targets for the treatment of both diseases. Historical data are provided to illustrate the above mentioned thesis, in the perspective of two epistemological concepts: the context of discovery proposed by Hans Reichenbach and the epistemological obstacle, proposed by Gaston Bachelard.

Cytoskeleton of hippocampal neurons as a target for valproic acid in an experimental model of depression.

BACKGROUND: Atrophy of pyramidal hippocampal neurons and of the entire hippocampus has been reported in experimental models of depression and in depressive patients respectively. We investigated the efficacy of valproic acid (VPA) for reversing a depressive-like behaviour and a cytoskeletal alteration in the hippocampus, the loss of the light neurofilament subunit (NF-L). METHODS: Depressive-like behaviour was induced by inescapable stress. Animals were divided into four groups: two to assess the response to 21 days of treatment with 200 mg/kg (I.P.) of valproic acid, and two in which the treatment was interrupted and the effects of VPA were evaluated 90 days later. Depressive-like behaviour was evaluated by the quantification of escape movements in a swimming test. NF-L was quantified by immunohistochemistry in dentate gyrus and CA3 of hippocampus. RESULTS: VPA corrected the depressive-like behaviour and reversed the diminution of NF-L in the hippocampus. Ninety days after the end of the treatment, and in contrast to the results previously obtained with fluoxetine, no recurrence of the depressive-like behaviour was observed. CONCLUSIONS: Despite interruption of the treatment, a long-lasting effect of VPA was observed. A possible relationship between the effect on NF-L and the prevention of depressive-like behaviour recurrence could be suggested.

[How do Argentinean psychiatrists treat depression?]. / ¿Cómo tratan los psiquiatras argentinos la depresión? Encuesta a una muestra de 402 psiquiatras acerca de sus hábitos prescriptivos para el tratamiento farmacológico.

OBJECTIVE: The objective of this study was to examine the prescribing practices of Argentinean psychiatrists in the treatment of major depression and to observe similarities and/or differences with some consensus or treatment guidelines. METHODOLOGY: Four hundred two psychiatrists were surveyed during a specialty meeting in October 2005. RESULTS: A total of 88.2 % of psychiatrists surveyed considered that every depressed patient must be treated with medication. The most prescribed antidepressants for outpatients were paroxetine, sertraline and fluoxetine. Venlafaxine was included for inpatients. The majority of psychiatrists indicated antidepressant therapy lasting from 12 to 24 months after remission of the first depressive episode. Antidepressant dosages remained unchanged during that period. A low percentage had used lithium or thyroid hormones as augmentation medications, the addition of other antidepressant being the most used augmentation strategy. The most prescribed antidepressant combination was dual antidepressants and SSRIs. Prescribing practices differed according to personal factors of the physicians. CONCLUSIONS: Discrepancies between clinical practice and treatment guidelines were observed. Further research over the underlying causes of these discrepancies and mechanisms to reduce them are necessary.

Pharmacokinetics of a novel spot-on formulation of praziquantel for dogs.

Praziquantel (PZQ) is an anthelmintic drug used both in humans and animals that can be administered through various routes. There are transdermal formulations for cats, but only oral or subcutaneous dosage forms for dogs. Given the fact that the cat's skin and the dog's skin have different characteristics, which in turn affect bioavailability, we developed a PZQ spot-on formulation for dogs. This study was aimed at determining the plasmatic behavior of topically administered PZQ (Labyes®) in adult dogs. Dogs were administered PZQ (14.5mg/kg PZQ, from a solution of 100mg/ml). Blood samples were drawn before treatment onset and at the following time points after PZQ administration: 1, 2, 4, 6, 12, 24 and 48h. PZQ plasma concentration was determined by ultra-high performance liquid chromatography (UPLC) coupled to tandem mass spectrometry (MS/MS). Observed maximum concentration (Cmax), area under the concentration-time curve from the time of drug administration to infinity (AUCinf) and time to maximum concentration (Tmax) were calculated for each animal, and mean±SD for each parameter was obtained. Results were as follows: Cmax=56.0±15ng/ml; AUCinf=910.2±220ng*h/ml, Tmax=5.0±1.1h. This is the first study to provide pharmacokinetic data of a praziquantel spot-on formulation for dogs.