Management of common mental disorders should take place in primary health or specialized care? Clinical decisions of psychiatrists from Latin American countries.

OBJECTIVE: The objective of our study was to explore clinical decisions of psychiatrists regarding the management of common mental disorders in primary care (PC) in four Latin Americans countries, through the application of clinical vignettes. METHODS: Using a cross-sectional design, we conducted a self-administered online questionnaire survey of psychiatrists from Bolivia, Brazil, Cuba, and Chile. The questionnaire covered sociodemographic and professional information. The psychiatrists' clinical decisions were assessed through three clinical vignettes representing typical PC cases of depression, anxiety, and somatization. RESULTS: 230 psychiatrists completed the online survey. Psychiatrists from Brazil were less likely to recognize depression as a mental disorder than those from Cuba (odds ratio (OR) = 0.30, 95% confidence interval (CI), 0.10 to 0.91, p < 0.04). Female gender (OR = 0.19, 95% CI, 0.04 to 0.91, p < 0.02) and older age (OR = 0.92, 95% CI, 0.87 to 0.97, p < 0.01) reduced the likelihood of agreement that depression cases should be treated by a Primary Care Physician (PCP). In the somatoform symptoms vignette, longer training duration increased the likelihood of agreement that treatment should be done by a psychiatrist instead of a PCP (OR = 1.19, 95% CI, 1.04 to 1.37, p < 0.01). In the anxiety vignette, females (OR = 2.38, 95% CI, 1.10 to 5.13, p < 0.01) and participants from Bolivia (compared with Cubans, OR = 4.19, 95% CI, 1.22 to 14.42, p < 0.02) were more likely to consider that these patients should be treated by a psychiatrist instead of a PCP. DISCUSSION: Most psychiatrist respondents agreed that patients with depression should be treated by PCPs and that somatoform and anxiety cases should be treated by psychiatrists. These results show that psychiatrists consider that they, and not PCPs, should treat patients with common mental disorders, regardless of the evidence showing that common mental disorders can be treated by primary care physicians in PC.

Neuropsychiatric Symptoms of Alzheimer's Disease in Down Syndrome and Its Impact on Caregiver Distress.

BACKGROUND: Neuropsychiatric symptoms (NPS) are non-cognitive manifestations common to dementia and other medical conditions, with important consequences for the patient, caregivers, and society. Studies investigating NPS in individuals with Down syndrome (DS) and dementia are scarce. OBJECTIVE: Characterize NPS and caregiver distress among adults with DS using the Neuropsychiatric Inventory (NPI). METHODS: We evaluated 92 individuals with DS (≥30 years of age), divided by clinical diagnosis: stable cognition, prodromal dementia, and AD. Diagnosis was determined by a psychiatrist using the Cambridge Examination for Mental Disorders of Older People with Down's Syndrome and Others with Intellectual Disabilities (CAMDEX-DS). NPS and caregiver distress were evaluated by an independent psychiatrist using the NPI, and participants underwent a neuropsychological assessment with Cambridge Cognitive Examination (CAMCOG-DS). RESULTS: Symptom severity differed between-groups for delusion, agitation, apathy, aberrant motor behavior, nighttime behavior disturbance, and total NPI scores, with NPS total score being found to be a predictor of AD in comparison to stable cognition (OR for one-point increase in the NPI = 1.342, p = 0.012). Agitation, apathy, nighttime behavior disturbances, and total NPI were associated with CAMCOG-DS, and 62% of caregivers of individuals with AD reported severe distress related to NPS. Caregiver distress was most impacted by symptoms of apathy followed by nighttime behavior, appetite/eating abnormalities, anxiety, irritability, disinhibition, and depression (R2 = 0.627, F(15,76) = 8.510, p < 0.001). CONCLUSION: NPS are frequent and severe in individuals with DS and AD, contributing to caregiver distress. NPS in DS must be considered of critical relevance demanding management and treatment. Further studies are warranted to understand the biological underpinnings of such symptoms.

Frontal-subcortical behaviors during Alzheimer's disease in individuals with Down syndrome.

There is evidence that frontal-subcortical circuits play an important role in the initial presentation of dementia in Down syndrome (DS), including changes in behavior, a decline in working memory and executive dysfunction. We evaluated 92 individuals with DS (≥30 years of age), divided into 3 groups by diagnosis-stable cognition, prodromal dementia, and Alzheimer's disease. Each individual was evaluated with an executive protocol developed for people with intellectual disabilities and was rated for behaviors related to frontal lobe dysfunction (disinhibition, executive dysfunction, and apathy) by an informant using the Frontal Systems Behavior Scale. Informant-reported behaviors related to frontal lobe dysfunction were found to correlate negatively with executive function performance. Disinhibition and executive dysfunction were associated with the clinical stage of dementia. The odds of having Alzheimer's disease increased in parallel with increases in the domain and total Frontal Systems Behavior Scale scores (p ≤ 0.5). Disinhibition, executive dysfunction and apathy should be taken into consideration during the clinical evaluation of adults with DS, and future studies should consider the intersection of neuropathology, brain connectivity, and behavior.