Bipolar Disorder Mixed Episodes: A Pragmatic Trial of a Public Health Treatment Effectiveness.

OBJECTIVES: To evaluate the effectiveness of an algorithm for the treatment of mixed episodes in bipolar disorder (BD) using the medications available under the Unified Health System (Sistema Único de Saúde) in Brazil. METHODS: The study included 107 individuals with BD in a current mixed episode, assessed biweekly for the outcomes of response and remission. The subjects were randomly assigned to start treatment with lithium, valproic acid, or carbamazepine, following a clinical protocol at a public outpatient clinic. Eligibility screening instruments, semistructured interview, and clinical psychiatric evaluation were used for diagnosis. To measure response and remission, the Hamilton Rating Scale for Depression and the Young Mania Rating Scale were used. A parameter of 50% or less in the symptom scales was used to define responses, as assessed by Kaplan-Meier time-event analysis. RESULTS: For the main outcome, response to treatment, all interventions proposed were proven to be effective, with no difference in response time for any of them. There was a lack of placebo control and blinding for intervention or outcomes. Individuals with mixed episodes in BD often face contradictory symptoms, and these inherent difficulties are the main obstacles to stabilize such a condition. CONCLUSIONS: The findings presented in this study show that the treatments available under the Unified Health System are able to reduce the overall burden of disease in terms of symptom reduction.

A naturalistic study of high-dose unilateral ECT among severely depressed inpatients: how does it work in the clinical practice?

BACKGROUND: Naturalistic studies can be useful tools to understand how an intervention works in the real clinical practice. This study aims to investigate the outcomes in a naturalistically treated depressed inpatients cohort, who were referred, or not, to unilateral ECT. METHODS: Depressed adults according to MINI admitted in a psychiatric unit were divided in unilateral ECT treated and non-ECT treated. Main outcomes were: depression improvement in Hamilton Rating Scale for Depression (HDRS-17) scores; response (HDRS-17 improvement ≥50 %); remission (HDRS-17 score ≤7); length of hospitalization. RESULTS: Forty-three patients were included in unilateral ECT group and 104 in non-ECT group. No differences of psychotic symptoms, melancholic features or past maniac episode were found between groups. Unilateral ECT group had a mean HDRS-17 score higher than non-ECT group at admission (ECT: 25.05 ± 1.03; non-ECT: 21.61 ± 0.69; p = 0.001), but no significant difference was found at discharge (ECT: 7.70 ± 0.81; non-ECT: 7.40 ± 0.51; p = 0.75). Unilateral ECT group had a larger HDRS-17 score reduction during treatment (ECT: 18.24 ± 1.18; non-ECT:14.20 ± 0.76; p = 0.004). There were no significant differences in response and remission rates between groups. Unilateral ECT group had longer mean duration of hospitalization in days (ECT: 35.48 ± 2.48; non-ECT: 24.57 ± 1.50; p < 0.001), but there were no difference in mean time of treatment (ECT group:27.66 ± 1.95; non-ECT: 24.57 ± 1.50; p = 0.25). CONCLUSIONS: Unilateral high-dose ECT is still a useful treatment option, in the real world clinical practice, to reduce the intensity of depressive symptoms in highly depressed inpatients.

Effectiveness and acceptability of accelerated repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant major depressive disorder: an open label trial.

BACKGROUND: Major depressive disorder (MDD) is a significant cause of worldwide disability and treatment resistance is common. High-frequency repetitive transcranial magnetic stimulation (HF-rTMS) has emerged as a treatment for MDD, and while efficacious, the daily commitment for typical 4-6 weeks of treatment poses a significant challenge. We aimed to determine the effectiveness and acceptability of an accelerated rTMS protocol for MDD. METHODS: In this naturalistic trial, 27 patients with moderate to severe chronic and treatment-resistant MDD were treated with twice-daily HF-rTMS (10 Hz) applied over the left dorsolateral prefrontal cortex for 2 consecutive weeks (60,000 pulses). The primary outcomes were rates of clinical remission and response (16-item Quick Inventory of Depressive Symptomatology post-treatment score ≤ 6, and ≥ 50% reduction, respectively). Secondary outcomes were self-reported anxious symptoms, depressive symptoms and quality of life, and dropout rates as a proxy for acceptability. RESULTS: Ten (37.0%) patients met criteria for clinical remission and 15 (55.6%) were classified as responders, with comparable outcomes for both moderate and severe MDD. Clinician-rated improvements in depressive symptoms were paralleled in self-reported depressive and anxious symptoms, as well as quality of life. No patient discontinued treatment. LIMITATIONS: This study is limited by short treatment duration that might be lengthened with corresponding improvements in effectiveness, limited duration of follow-up, small sample size, and an open-label design requiring randomized controlled replication. CONCLUSION: An accelerated protocol involving twice-daily sessions of HF-rTMS over the left DLPFC for 2 weeks was effective in treatment-resistant MDD, and had excellent acceptability. Additional research is required to optimize accelerated rTMS treatment protocols and determine efficacy using sham-controlled trials.

Effectiveness and acceptability of deep brain stimulation (DBS) of the subgenual cingulate cortex for treatment-resistant depression: a systematic review and exploratory meta-analysis.

BACKGROUND: Deep brain stimulation (DBS) applied to the subgenual cingulate cortex (SCC) has been recently investigated as a potential treatment for severe and chronic treatment-resistant depression (TRD). Given its invasive and experimental nature, a comprehensive evaluation of its effectiveness and acceptability is of paramount importance. Therefore, we conducted the present systematic review and exploratory meta-analysis. METHODS: We searched the literature for English language prospective clinical trials on DBS of the SCC for TRD from 1999 through December 2012 using MEDLINE, EMBASE, PsycINFO, CENTRAL and SCOPUS, and performed a random effects exploratory meta-analysis using Event Rates and Hedges׳ g effect sizes. RESULTS: Data from 4 observational studies were included, totaling 66 subjects with severe and chronic TRD. Twelve-month response and remission rates following DBS treatment were 39.9% (95% CI=28.4% to 52.8%) and 26.3% (95% CI=13% to 45.9%), respectively. Also, depression scores at 12 months post-DBS were significantly reduced (i.e., pooled Hedges׳ g effect size=-1.89 [95% CI=-2.64 to -1.15, p<0.0001]). Also, there was a significant decrease in depression scores between 3 and 6 months (Hedges׳ g=-0.27, p=0.003), but no significant changes from months 6 to 12. Finally, dropout rates at 12 months were 10.8% (95% CI=4.3% to 24.4%). LIMITATIONS: Small number of included studies (most of which were open label), and limited long-term effectiveness data. CONCLUSIONS: DBS applied to the SCC seems to be associated with relatively large response and remission rates in the short- and medium- to long-term in patients with severe TRD. Also, its maximal antidepressant effects are mostly observed within the first 6 months after device implantation. Nevertheless, these findings are clearly preliminary and future controlled trials should include larger and more representative samples, and focus on the identification of optimal neuroanatomical sites and stimulation parameters.

Personality dimensions and deep repetitive transcranial magnetic stimulation (DTMS) for treatment-resistant depression: a pilot trial on five-factor prediction of antidepressant response.

BACKGROUND: Prognostication is poor in repetitive transcranial magnetic stimulation (rTMS) treatment for major depressive disorder (MDD). Personality traits, particularly extraversion and neuroticism, have attracted increasing attention for both trait- and state-dependent characteristics in predicting response to pharmacotherapy, psychotherapy, and more recently to therapeutic neuromodulation for MDD. The advent of deep rTMS (DTMS) allows stimulation of deeper cortical regions, and we aimed to prospectively characterize personality dimensions and antidepressant response to DTMS in treatment-resistant MDD. METHODS: A convenience sample of 15 patients with treatment-resistant MDD received four weeks of daily sessions of DTMS (20 Hz, 3000 pulses/session) of the left dorsolateral prefrontal cortex (DLFPC). At baseline and at the conclusion of treatment, patients completed the Big Five Inventory, a five-factor assessment of major personality dimensions. Clinical response was measured using the 21-item Hamilton Depression Rating Scale. RESULTS: Four weeks of DTMS treatment were not associated with changes in personality measures. Clinical remission was associated with higher baseline levels of agreeableness (score ≥ 29:100% sensitive and 72.7% specific) and conscientiousness (score ≥ 30:75% sensitive and 81.8% specific). Levels of agreeableness and extraversion were linearly associated with antidepressant response. Neuroticism was not associated with the antidepressant effects of DTMS in this cohort. CONCLUSIONS: Five-factor personality assessment may have prognostic value in DTMS for resistant MDD. Agreeableness, extraversion, and conscientiousness are associated with decreases in depressive symptoms during treatment with DTMS.

Depression and perceptions of quality of life of breast cancer survivors and their male partners.

PURPOSE/OBJECTIVES: To assess differences in ways women with breast cancer evaluate their own quality of life (QOL) compared to perceptions of their partners and to identify factors that influence dissimilarities in QOL perceptions. DESIGN: Cross-sectional study. SETTING: Breast unit in southern Brazil. SAMPLE: 73 women with stage I-III breast cancer and their partners. Most participants were middle-aged, with partners of long-term cohabitation. METHODS: QOL was evaluated with the World Health Organization Quality of Life-Brief Form (WHOQOL-BREF), Beck Depression Inventory, and WHOQOL-BREF adapted for a third person. MAIN RESEARCH VARIABLES: Demographic and clinical features, QOL, partners' perceptions, and depression. FINDINGS: No differences were found between the perceptions of QOL in different domains between the patients and their partners. Depression in women seemed to be the only variable that interfered in a consistent manner with the congruity of the QOL assessments made by patients and their partners. CONCLUSIONS: Partners of women with breast cancer may be viewed as reliable surrogates to assess patients' QOL. IMPLICATIONS FOR NURSING: Partners' judgments of patients' QOL may be important in some circumstances, particularly when patients are not able to answer questions about their own QOL because of cognitive or functional limitations. Nurses must be aware that partners are the most frequent informal caregivers and should be included in the entire treatment process.

Significant improvement in the quality of life of Brazilian depressed outpatients 12 weeks following the start of antidepressants.

Studies on the impact of depression should go beyond estimating its prevalence and the severity of symptoms to include investigations that seek to establish how it influences the quality of life (QOL) of the affected individuals. Although some depression trials have included QOL measures, assessments were mostly retrospective and relatively infrequent. In the present investigation, 73 patients presenting a severe episode of major depression were assessed by the WHOQOL BREF and the Beck Depression Inventory (BDI) at the start of antidepressant treatment and again after a mean of 12 weeks. After analyses, depressed patients' QOL scores significantly improved in all the assessed domains (i.e., physical health, psychological, social relations, environmental, and overall QOL) over the study period. Additionally, there was a significant improvement in depressive symptoms between test and retest. Effect sizes for these differences ranged from 0.49 to 1.08 (i.e., medium to large effects). After multiple regression analyses, age, psychiatric comorbidity, and depressions scores were independent predictors of some of the QOL domains (i.e., physical, psychological, and overall). In conclusion, antidepressant treatment seems to be associated with significant improvements in multiple QOL domains in patients with severe major depression. However, our findings are preliminary and suggest that additional controlled and long-term studies are needed.

Double depression in adult psychiatric outpatients in Brazil: distinct from major depression?

This study examines whether distinct symptom profiles, patterns of comorbidity, and suicidal symptoms uniquely characterize individuals diagnosed with double depression (DD) by comparing Brazilians with DD to those with major depressive disorder (MDD). One hundred forty two psychiatric outpatients (ages 20-77 mean=48.8, S.D.=13.2; DD, n=23; MDD, n=119) participated in structured diagnostic interviews and completed self-report measures of depressive symptoms, suicidality, and family history of mental disorders. Patients with DD exhibited a more severe symptom profile than those with MDD, as evidenced by a higher number of depressive symptoms and more intense suicidal ideation. They also appeared to be qualitatively different from individuals with MDD, as evidenced by distinct comorbidity patterns, quality of life reports, and anhedonic features. These results may be important in understanding the phenomenology of DD in psychiatric outpatients by informing diagnostics, psychotherapy, and psychotherapeutic treatment of DD.

Reliability and validity of the WHOQOL BREF in a sample of Brazilian outpatients with major depression.

The present study assessed the psychometric properties of the Brazilian version of the World Health Organization's Quality of Life Instrument--Short Version (WHOQOL BREF) in a sample of 89 adult outpatients with major depression. After analyses, the WHOQOL BREF showed good internal consistency, and was sensitive to improvement after treatment with antidepressants. Convergent validity between the WHOQOL BREF and the Beck Depression Inventory was statistically significant, as well as WHOQOL BREF's ability to discriminate between outpatients on the basis of their level of depression. In conclusion, the WHOQOL BREF seems to be a psychometrically valid and reliable instrument that it is suitable for evaluating the quality of life of Brazilian-speaking depressed outpatients.

Four studies on how past and current suicidality relate even when "everything but the kitchen sink" is covaried.

T. E. Joiner's (2004, in press) theory of suicidal behavior suggests that past suicidal behavior plays an important role in future suicidality. However, the mechanism by which this risk is transferred and the causal implications have not been well studied. The current study provides evaluation of the nature and limits of this relationship across 4 populations, with varying degrees of suicidal behavior. Across settings, age groups, and impairment levels, the association between past suicidal behavior and current suicidal symptoms held, even when controlling for strong covariates like hopelessness and symptoms of various Axis I and II syndromes. Results provide additional support for the importance of past suicidality as a substantive risk factor for later suicidal behavior.

Quality of life in unipolar and bipolar depression: are there significant differences?

In the present investigation, we compared the impact of illness on quality of life (QOL) in adult outpatients with unipolar (N = 89) and bipolar (N = 25) depression. While attending a university hospital in southern Brazil, patients completed the WHO's QOL Instrument-Short Version and the Beck Depression Inventory. After analyses, patients with bipolar depression reported significantly lower scores on the psychological QOL domain (p = .013) than patients with unipolar depression. There were no significant differences between the study groups in terms of social and demographic variables, in the other QOL domains assessed (i.e., physical health, social relationships, and environmental), and in the severity of depressive symptoms. In conclusion, our findings suggest that patients with bipolar and unipolar depressions have different QOL profiles, and that this difference is probably independent of the severity of the mood disturbance and might be related to the higher rates of suicide observed in the bipolar population.

[WHOQOL-OLD Project: method and focus group results in Brazil]. / Projeto WHOQOL-OLD: método e resultados de grupos focais no Brasil.

OBJECTIVES: Exploring the conditions that allow satisfactory quality of life in old age is an issue of scientific and social relevance. Thus, the objective of the study was to describe a quality of life assessment method for the elderly and present the results from focus groups conducted among old people in good health and ill health, as well as their caregivers. METHODS: The methodology used in the WHOQOL-OLD project is the same as utilized in the development of other WHOQOL modules. Five focus groups were conducted in Brazil. The sampling procedure was done according to convenience. Eighteen old people and five caregivers took part in the focus groups. All the focus groups followed a pre-established methodology. RESULTS: A tendency towards making an association between quality of life and wellbeing and feeling well was observed. The responses spontaneously included the 6 domains proposed in WHOQOL-100, thus corroborating the multidimensional nature of this construction. Nineteen out of the 24 original facets of this instrument were cited as relevant, and the five facets not spontaneously remembered were not concentrated in a single domain. When questioned about the importance of each of the 24 facets of WHOQOL-100, the groups considered all of them to be relevant. However, suggestions for modifications to five facets were made. Additional items were also examined and considered relevant for assessing quality of life among the elderly, by both the old people and the caregivers. CONCLUSIONS: The results corroborate the hypothesis that old people constitute a particular group and, as such, they have relevant specific characteristics. Thus, an appropriate instrument for assessing quality of life among the elderly needs to consider such matters.

Projeto WHOQOL-OLD: método e resultados de grupos focais no Brasil / WHOQOL-OLD Project: method and focus group results in Brazil

OBJETIVO: A investigaçäo sobre as condições que permitem uma boa qualidade de vida na velhice é de interesse científico e social. Assim, o estudo objetivou apresentar a metodologia utilizada e os resultados dos grupos focais para avaliaçäo da qualidade de vida do idoso. MÉTODOS: A metodologia do projeto WHOQOL-OLD é a mesma utilizada no desenvolvimento de outros módulos do WHOQOL. Foram realizados cinco grupos focais no Brasil. O método amostral foi o de conveniência. Dezoito idosos e cinco cuidadores participaram dos grupos focais. Todos os grupos obedeceram a uma metodologia pré-estabelecida. RESULTADOS: Observou-se uma tendência de associaçäo entre qualidade de vida e bem-estar ou sentir-se bem. Espontaneamente, as respostas incluíram os seis domínios propostos no WHOQOL-100, reforçando a multidimensionalidade do construto. Das 24 facetas originais, 19 foram citadas como relevantes, sendo que as cinco facetas näo espontaneamente lembradas näo se centraram em um único domínio. Quando perguntados sobre a importância de cada uma das 24 facetas do WHOQOL-100, os grupos consideraram-nas todas relevantes. Foram sugeridas modificações para serem aplicadas a idosos para cinco facetas. Itens adicionais também foram examinados e considerados relevantes para a avaliaçäo de qualidade de vida em idosos, tanto pelos idosos entrevistados como pelos cuidadores. CONCLUSÕES: Os resultados corroboram com a hipótese de que os idosos constituem um grupo particular e, como tal, apresentam especificidades de importante relevância para a qualidade de vida. Assim, um instrumento adequado para a avaliaçäo da qualidade de vida de idosos tem que necessariamente contemplar esses aspectos.

[Posttraumatic stress disorder and major depression]. / Transtorno de estresse pós-traumático e depressão maior.

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorder, especially with major depression. However, the relationship between these disorders and the treatment of this complex clinical entity are only now being addressed in the specialized literature. Some authors argued that they are two distinct entities, whereas others defended the hypothesis that the high prevalence of this comorbidity may represent an artifact derived from the diagnostic criteria currently used. Regarding the treatment of PSTD comorbid with major depression, the available data from controlled studies are insufficient to point out for a specific approach, although some small trials reported the usefulness of combining selective serotonin reuptake inhibitors and cognitive therapy.

Psychache and suicidality in adult mood disordered outpatients in Brazil.

Shneidman (e.g., 1998) has theorized that psychache--general psychological and emotional pain that reaches intolerable intensity--is an important suicide-related variable, and indeed, represents a source of suicidal behavior. This conceptualization, while prominent and clinically and intuitively appealing, has received relatively little empirical scrutiny. In this study, we determined whether an index closely related to psychache, psychological quality of life, would display a special and resilient association to suicidality among 60 adult psychiatric outpatients in Brazil. All patients underwent structured clinical interviews and completed various clinical and quality-of-life measures. We found that the association between psychological quality of life and suicidality remained, even when depression, hopelessness, and other domains of quality of life were controlled. Psychache appears to deserve its place among key suicide-related variables, and deserves the attention of clinicians working with suicidal people.

Quality of life: a brand new concept for research and practice in psychiatry

Desde os anos 70, a avaliação da qualidade de vida (QV) cresceu de uma atividade relativamente restrita para uma disciplina formal com uma estrutura teórica coesa, métodos consagrados e diversas aplicações. Nos últimos anos, a QV vem se tornando cada vez mais popular como uma variável útil para determinar o impacto global das doenças e dos tratamentos médicos a partir da perspectiva do paciente. Nesse artigo de atualização, nós descrevemos os instrumentos mais freqüentemente utilizados e discutimos as questões conceituais e práticas envolvidas na avaliação da QV quando aplicada ao estudo dos transtornos mentais. Além disso, nós apresentamos uma definição unificada de QV, recentemente desenvolvida pela Organização Mundial de Saúde. Por fim, concluímos que as medidas de QV são potencialmente úteis para aplicação na pesquisa e na prática clínica em Psiquiatria – especialmente para demonstrar o impacto das doenças mentais e o possível benefício das intervenções terapêuticas.

Notes on antipsychiatry.

The present paper aims to provide a review of the history and basic principles of the antipsychiatric movement, as well as to discuss the work of its most important theorists. The authors searched recent literature, as well as drawing upon some of the basic antipsychiatric texts. Antipsychiatry emerged as an international movement during the 1960s as part of the historic tumult of the period rather than as a result of the evolution of scientific ideas. Antipsychiatrists radically opposed what they understood as a hospital-centered medical specialty legally empowered to treat and institutionalize mentally disordered individuals. Indeed, many antipsychiatrists argued against the very existence of mental disorders themselves. After the 1970s, the antipsychiatry movement became increasingly less influential, due in particular to the rejection of its politicized and reductionistic understanding of psychiatry.

Transtorno de estresse pós-traumático e depressäo maior / Posttraumatic stress disorder and major depression

Estudos epidemiológicos indicam, claramente, que o transtorno de estresse pós-traumático (TEPT) está se tornando um importante problema de saúde em termos globais, ainda que continue sendo pouco diagnosticado e tratado de forma inapropriada. O TEPT comumente ocorre em comorbidade com outros transtornos psiquiátricos, especialmente com a depressäo maior. Entretanto, a relaçäo entre esses transtornos e o tratamento dessa complexa entidade clínica apenas recentemente passou a receber atençäo da literatura especializada. Alguns autores argumentaram que elas säo duas entidades distintas, enquanto outros defenderam a hipótese de que a alta prevalência dessa comorbidade pode representar um artefato derivado dos critérios diagnósticos atualmente utilizados. Com relação ao tratamento do TEPT comórbido com depressäo maior, os dados disponíveis na literatura säo insuficientes e näo apontam para nenhuma abordagem específica, embora alguns ensaios clínicos pequenos tenham relatado a utilidade da combinaçäo de inibidores seletivos da recaptaçäo da serotonina com terapia cognitiva