Understanding the journey of patients with depression in Brazil: A systematic review.

Despite having an organized mental health law and policy, a majority of patients with depression remain underreported and undertreated in Brazil. The study aimed to quantitatively map and identify the deficiencies in patient journey touchpoints in terms of awareness, screening, diagnosis, treatment, adherence, and control for depression in Brazil using a semi-systematic approach highlighting the knowledge gaps in the existing literature. A structured search of Embase, MEDLINE, and BIOSIS databases was conducted to identify the relevant studies published in English, Portuguese, and Spanish from 2006 to 2021. An unstructured search was also conducted on Google or government websites with no restrictions. To address the data gaps, anecdotal data were also considered. Weighted or simple means were calculated for the pooled data. Of 3175 articles retrieved, 10 articles met the inclusion criteria. Synthesized evidence indicates that the pooled prevalence of depression in Brazil ranged from 4.1% to 21.8%; 42.4% of patients had awareness of depression, 37.5% underwent screening, 18.7% had a diagnosis, and 54.4% received treatment. No data on adherence and control were available. The study findings highlight the need for more research to accurately estimate the common patient journey touchpoints for depression to achieve better clinical outcomes in Brazil.

Understanding the journey of patients with depression in Brazil: A systematic review

Abstract Despite having an organized mental health law and policy, a majority of patients with depression remain underreported and undertreated in Brazil. The study aimed to quantitatively map and identify the deficiencies in patient journey touchpoints in terms of awareness, screening, diagnosis, treatment, adherence, and control for depression in Brazil using a semi-systematic approach highlighting the knowledge gaps in the existing literature. A structured search of Embase, MEDLINE, and BIOSIS databases was conducted to identify the relevant studies published in English, Portuguese, and Spanish from 2006 to 2021. An unstructured search was also conducted on Google or government websites with no restrictions. To address the data gaps, anecdotal data were also considered. Weighted or simple means were calculated for the pooled data. Of 3175 articles retrieved, 10 articles met the inclusion criteria. Synthesized evidence indicates that the pooled prevalence of depression in Brazil ranged from 4.1% to 21.8%; 42.4% of patients had awareness of depression, 37.5% underwent screening, 18.7% had a diagnosis, and 54.4% received treatment. No data on adherence and control were available. The study findings highlight the need for more research to accurately estimate the common patient journey touchpoints for depression to achieve better clinical outcomes in Brazil.

A randomized controlled trial comparing lithium plus valproic acid versus lithium plus carbamazepine in young patients with type 1 bipolar disorder: the LICAVAL study.

BACKGROUND: Treatment of bipolar disorder (BD) usually requires drug combinations. Combinations of lithium plus valproic acid (Li/VPA) and lithium plus carbamazepine (Li/CBZ) are used in clinical practice but were not previously compared in a head-to-head trial. OBJECTIVE: The objective of this trial was to compare the efficacy and tolerability of Li/VPA versus Li/CBZ in treating type 1 BD in any phase of illness in young individuals. METHODS: LICAVAL was a randomized, unicenter, open-label, parallel-group trial that was conducted from January 2009 to December 2012 in a tertiary hospital in São Paulo, Brazil. Participants were between 18 and 35 years old and were followed up for 2 years. Our primary outcome was the number of participants achieving/maintaining response and remission during the acute and maintenance phases of BD treatment, respectively. Other outcomes assessed were symptom severity and adverse events throughout the study. In the analysis of the primary outcome, we compared groups by using a two-way repeated measures analysis of variance and estimated effect sizes by using Cohen's d. RESULTS: Of our 64 participants, 36 were allocated to Li/VPA and 28 to Li/CBZ. Our sample was composed predominantly of females (66.6%) and the average age was 27.8 years. A total of 27 (45.0%) participants had depression, 17 (28.3%) had mania/hypomania, and 16 (26.7%) had a mixed state. We found no between-group differences in CGI-BP (Clinical Global Impression Scale modified for use in bipolar disorder) scores (P = 0.326) or in any other outcome. Side effects differed significantly between groups only in the first week of treatment (P = 0.021), and there were more side effects in the Li/VPA group. Also, the Li/VPA group gained weight (+2.1 kg) whereas the Li/CBZ group presented slight weight loss (-0.2 kg). CONCLUSION: Our study suggests that Li/VPA and Li/CBZ have similar efficacy and tolerability in BD but that Li/CBZ might have metabolic advantages in the long term. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT00976794 . Registered on September 9, 2009.

Clínica da Atenção Psicossocial: transtornos do humor

Material utilizado no módulo de Clínica da Atenção Psicossocial do curso de capacitação em Saúde Mental produzido pela UNA-SUS/UFMA. Apresenta as causas dos transtornos do humor, as dimensões em se enquadram e seus tipos. Aborda, ainda, os transtornos depressivos, destacando a depressão em populações específicas e episódios de mania.

The ARIQUELI study: potentiation of quetiapine in bipolar I nonresponders with lithium versus aripiprazole.

BACKGROUND: The treatment of bipolar disorder (BD) remains a challenge due to the complexity of the disease. Current guidelines represent an effort to assist clinicians in routine practice but have several limitations, particularly concerning long-term treatment. The ARIQUELI (efficacy and tolerability of the combination of lithium or aripiprazole in young bipolar non or partial responders to quetiapine monotherapy) study aims to evaluate two different augmentation strategies for quetiapine nonresponders or partial responders in acute and maintenance phases of BD treatment. METHODS/DESIGN: The ARIQUELI study is a single-site, parallel-group, randomized, outcome assessor-blinded trial. BD I patients according to the DSM-IV-TR, in depressive, manic/hypomanic or mixed episode, aged 18 to 40 years, are eligible. After diagnostic assessments, patients initiated treatment in phase I with quetiapine. Nonresponders or partial responders after 8 weeks are allocated into one of two groups, potentiated with either lithium (0.5 to 0.8 mEq/l) or aripiprazole (10 or 15 mg). Patients will be followed up for 8 weeks in phase I (acute treatment), 6 months in phase II (continuation treatment) and 12 months in phase III (maintenance treatment). Outcome assessors are blinded to the treatment. The primary outcome is the evaluation of changes in mean scores on the CGI-BP-M between baseline and the endpoint at the end of each study phase. DISCUSSION: The ARIQUELI study is currently in progress, with patients undergoing acute treatment (phase I), potentiation (phase II) and maintenance (phase III). The study will be extended until January 2015. Trials comparing lithium and aripiprazole with potentiate treatment in young BD I nonresponders to quetiapine in monotherapy can provide relevant information on the safety of these drugs in clinical practice. Long-term treatment is an issue of great importance and should be evaluated further through more in-depth studies given that BD is a chronic disease. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01710163.

Effect of estrogen replacement therapy on symptoms of depression and anxiety in non-depressive menopausal women: a randomized double-blind, controlled study.

The efficacy of estrogen replacement therapy (ERT) for mood disturbances associated with menopause has yet to be firmly established. The objective of this study was to investigate the efficacy of ERT for improving mood and anxiety of non-depressive postmenopausal women. This double-blind, randomized, placebo-controlled study involved two treatment groups: one receiving conjugated equine estrogens (CEEs; 0.625 mg/day) and the other placebo, for six cycles of 28 days each. Subjects were hysterectomized, healthy, non-depressive (according to Schedule for Affective Disorders and Schizophrenia, Life Time Version [SADS-L]) women. Depressive and anxiety symptoms were assessed with the Beck Depression Inventory (BDI), and the Hamilton Anxiety Scale (HAMA), respectively. The Profile of Mood States (POMS) and other scales were used to characterize symptoms. In both groups, BDI scores were significantly lower at cycles 1, 2, 3, and 6, compared with baseline assessments (p<0.01). Anxiety scores for both groups significantly improved from cycle 3 to study endpoint. The only significant difference favoring the active group occurred at cycle 1. POMS scores were significantly improved at the end of cycles 1, 2, 3 and 6 among treated subjects and at the end of cycles 2, 3, and 6 among placebo subjects. ERT is not associated with improvements in mood or anxiety symptoms in non-depressive, hysterectomized, postmenopausal women.

Estrogen replacement therapy and cognitive functions in healthy postmenopausal women: a randomized trial.

This study aimed to evaluate the effect of estrogen replacement therapy on verbal cognitive performance of middle-aged postmenopausal women. Middle-aged (40 to 59 years) hysterectomized, oligosymptomatic women receiving 0.625 mg/day of conjugated equine estrogens (N = 27) or placebo (N = 32) in a double-blind parallel group design were compared according to their performance on a verbal memory battery before and after six 28-day cycles of treatment. Both groups had similar age and educational level. The estrogen group performed better on digit span-forward and on the recall of the easy stimuli on the verbal-paired associates test regardless of age, education, physical symptoms, number of years of menopause, or blood estradiol levels. However, the small magnitude of difference in the effect on attentional span suggests that the estrogen-related improvement is unlikely to be of clinical relevance. Estrogen replacement therapy did not improve verbal memory in middle-aged, hysterectomized, postmenopausal, asymptomatic women.

Prevalência de depressão em mulheres idosas com fratura de quadril / Prevalence of depression in older women with hip fracture

CONTEXTO: A fratura de quadril possui elevada prevalência, principalmente em mulheres idosas. A depressão possui elevada prevalência nas mulheres e dados da literatura sugerem a existência de uma associação entre depressão e risco de fratura de quadril. Entretanto, não encontramos estudos brasileiros investigando especificamente esse tópico. OBJETIVOS: Investigar, em mulheres idosas, a prevalência de episódio depressivo maior precedendo a fratura de quadril e comparar com a prevalência de depressão em um grupo controle. MÉTODOS: Foram avaliadas 65 mulheres idosas, sendo 30 com fratura de quadril e 35 sem fratura de quadril. Para avaliar a depressão, utilizaram-se a Entrevista Clínica Estruturada para DSM-IV (SCID) e a Escala de Hamilton para Depressão na versão de 31 itens (HAM-D-31); para a avaliação do estado cognitivo, utilizou-se o Mini-Exame do Estado Mental (Mini Mental State Examination " MMSE). RESULTADOS: As pacientes com fratura de quadril apresentaram uma tendência para maior prevalência de história de episódio depressivo maior (p = 0,08) e menor pontuação para o MMSE. CONCLUSÕES: Neste estudo preliminar, encontrou-se uma tendência para maior prevalência de depressão em mulheres idosas com fratura de quadril. Estudos multicêntricos são recomendados para investigar essa possível associação na população brasileira.

BACKGROUND: Hip fracture has a high prevalence, especially among older women. Depression is common among females and data have suggested the existence of an association between depression and risk of hip fracture. However, we could not find Brazilian studies focusing specifically this issue. OBJECTIVES: To investigate, in elderly women, the prevalence of major depressive episode previously to the hip fracture and compare with the prevalence of depression in a control group. METHODS: We evaluated 65 elderly women, 30 with hip fracture and 35 without a hip fracture. To evaluate the depression we used the Structured Clinical interview for DSM-IV (SCID) and the 31-item version of the Hamilton Rating Scale for Depression (HAM-D-31), and to evaluate the cognitive state we used the Mini Mental State Examination (MMSE). RESULTS: Patients with hip fracture showed a trend for increased prevalence of previous major depressive episode (p = 0.08) and lower scores on the MMSE. DISCUSSION: In this preliminary study we found a trend for increased prevalence of depression in elderly women with hip fracture. Multicenter studies are warranted to investigate this possible association in the Brazilian population.

Depressão e comorbidades clínicas / Depression and medical comorbidity

A associação entre depressão e doenças clínicas é muito freqüente, levando a pior evolução tanto do quadro psiquiátrico como da doença clínica, com menor aderência às orientações terapêuticas, além de maior morbidade e mortalidade. A depressão muitas vezes é subdiagnosticada e subtratada, principalmente pela presença de sintomas depressivos, que também podem ocorrer em doenças crônicas, como fadiga e anorexia. Diversas doenças estão claramente associadas à depressão, com maior destaque para as doenças cardiovasculares, endocrinológicas, neurológicas, renais, oncológicas e outras síndromes dolorosas crônicas. Os autores discutem as evidências na literatura que demonstram essa associação, com enfoque nos avanços em fisiopatologia e terapêutica psiquiátrica.

Efeito da terapia de reposicao estrogenica no humor em mulheres menopausadas / Effects of estrogen replacement therapy on mood in postmenopausal women: a review of the literature

Foram revisados estudos intervencionistas e epidemiologicos que procuraram identificar o efeito da terapia de reposicao estrogenica sobre o humor em mulheres menopausadas. A maioria desses estudos apresenta desenhos experimentais muito diferentes entre si, e importantes limitacoes metodologicas sao encontradas em muitos deles...

Terapia com estrogenos conjugados no humor em mulheres menopausadas: resultados preliminares / Conjugated estrogens therapy and mood in postmenopausal women: preliminary results

Para estudar o efeito da terapia de reposicao estrogenica sobre medida valida e confiavel do humor (Escala de Depressao de Beck) apos a menopausa...

Clozapina no transtorno bipolar refratario / Clozapine in refractory bipolar disorder

Os autores relatam o caso de um paciente de 36 anos, portador de transtorno bipolar tipo I, com predominio de episodios maniacos, refratario a varios esquemas terapeuticos ha mais de uma decada. Com a introducao da clozapina em associacao com valproato de sodio, houve remissao do quadro de humor e foi possivel reduzir a sua politerapia farmacologica a apenas duas medicacoes. Uma revisao de literatura sobre o papel da clozapina no transtorno bipolar...

Alcoolismo na mulher e sindrome pre-menstrual: existem associacoes ? / Alcoholism in womem and the premenstrual syndrome: are there associations ?

O alcoolismo na mulher e uma importante questao atual e as possiveis correlacoes com a sindrome pre-menstrual sempre geraram interesse cientifico, como possivel fator etiologico ou como comorbidade frequente...

Efeito do tratamento da depressão sobre o esvaziamento gástrico / Treatment of depression effect on the gastric emptying

O esvaziamento gástrico foi medido por meio de refeição sólida marcada com 99mTc em 11 pacientes que atendiam os critérios de "depressão maior" do DSM-III-R antes e após o tratamento com fluoxetina (20 a 40 mg por dia) durante nove semanas. Após o tratamento não se observou redução no tempo para o esvaziamento gástrico de metade da refeição de prova (T1/2) em relação a antes do tratamento. Pode-se, no entanto, separar os pacientes em dois grupos: 1) Os que exibiram resposta ao antidepressivo (redução do escore da Escala de Depressão de Hamilton > 50 por cento) e apresentaram redução significativa do T1/2 (p<0,001) e 2) Os pacientes que, sem resposta ao tratamento (redução do escore da Escala de Depressão de Hamilton 50 por cento), não apresentaram redução do T 1/2 (p>0,10). Concluímos que a alteração da velocidade do esvaziamento gástrico pode estar correlacionada à resposta ao tratamento antidepressivo e que sua redução ou aumento não pode ser atribuída à ação farmacológica da fluoxetina sobre o estômago, mas antes ao efeito da melhoria da depressão sobre a motilidade gástrica.

O uso do lítio em psiquiatria / Lithium utilization in psychiatry

Faz parte de um programa educacional voltado para a populaçäo que usa mediciamentos estabilizadores do humor, particularmente os sais de lítio. Consideramos que tanto o paciente e seus familiares, quanto o médico e sua equipe, säo responsáveis pelo tratamento. O lítio e seu uso em psiquiatria foram baseados na experiência do Grupo de Estudos de Doenças Afetivas (GRUDA) do Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de Säo Paulo (IPQ-HC-FMUSP) e em publicaçöes científicas