Update on the use and management of lithium in neuropsychiatry / Actualización en el uso y el manejo del litio en neuropsiquiatría.

Lithium is an alkaline metal, used for more than 60 years in psychiatry, and currently considered the gold standard in the treatment of bipolar disorder (BD). According to recent evidence, this active ingredient is useful for the treatment of a wide spectrum of clinical varieties of affective disorders. In addition, it is estimated that lithium reduces the risk of suicide and suicidal behavior in people with mood disorders. On the other hand, some novel studies have shown that the cation has a potential efficacy for the treatment of other neuropsychiatric processes, such as the likelihood of reducing the risk of dementia and slowing down the development of neurodegenerative diseases. Despite the enormous evidence in favor of the use of lithium, it is known that, in Argentina, medications containing it are prescribed less than expected. In view of all this, the Asociación Argentina de Psiquiatría Biológica (Argentine Association of Biological Psychiatry) (AAPB or AABP) convened a group of experts to review the available scientific literature and prepare an updated document on the management and use of lithium in neuropsychiatry. In addition to the use of the ion in daily clinical practice, the scope of this review includes other contents that have been considered of interest for the psychiatrist, such as certain pharmacological and pharmacogenetic aspects, possible clinical predictors of response to treatment with lithium, management of ion during perinatal period, management of lithium in child and adolescent population, management of adverse effects linked to cation and interactions with drugs and other substances.

El litio es un metal alcalino, usado hace más de 60 años en psiquiatría, y actualmente es considerado el estándar de oro en el tratamiento del trastorno bipolar (TB). De acuerdo con la evidencia reciente, este principio activo es útil para el tratamiento de un amplio espectro de variedades clínicas de los trastornos afectivos. Además, se estima que desde hace tiempo el litio reduce el riesgo de suicidio y de comportamiento suicida en personas con trastornos del estado de ánimo. Por otro lado, algunos estudios novedosos han demostrado que el catión posee una potencial eficacia para el tratamiento de otros procesos neuropsiquiátricos, tales como la probabilidad de disminuir el riesgo de demencia y la de ralentizar el desarrollo de enfermedades neurodegenerativas. A pesar de la enorme evidencia a favor de la utilización del litio, se sabe que, en la Argentina, las especialidades medicinales que lo contienen se prescriben menos de lo esperado. En virtud de todo lo mencionado, la Asociación Argentina de Psiquiatría Biológica (AAPB) convocó a un grupo de expertos para revisar la literatura científica disponible y elaborar un documento actualizado sobre el manejo y el uso del litio en neuropsiquiatría. Además de la utilización del ion en la práctica clínica diaria, el alcance de esta revisión incluye otros contenidos que se han considerado de interés para el médico psiquiatra, tales como ciertos aspectos farmacológicos y farmacogenéticos, posibles predictores clínicos de la respuesta al tratamiento con litio, el manejo del ion durante el período perinatal, el manejo de litio en la población infantojuvenil, el manejo de los efectos adversos vinculados con el catión y las interacciones con medicamentos y otras sustancias.

[Argentine consensus on the diagnosis and therapeutics of treatment resistant schizophrenia]. / Consenso argentino sobre diagnóstico y tratamiento de la esquizofrenia resistente al tratamiento.

Approximately 30% of people with schizophrenia fail to respond to first-line antipsychotic treatment which impacts the burden of the disease. Treatment-resistant schizophrenia (TRS) denotes patients with failure to respond to at least two adequate trials of different antipsychotics. Clozapine is a unique drug approved for treating treatment-resistant schizophrenia, however 1/3 of patients fail to respond to clozapine. Even though different strategies have been proposed for treating clozapine-resistant schizophrenia, the evidence is very limited, unclear, and of poor quality. A formal literature search was conducted and then, panel members were asked to complete 35 questions addressing different aspects of TRS. A modified Delphi method was used to unify expert opinion and achieve consensus. The expert consensus in diagnostic and treatment of TRS is the result of experts from the main national scientific societies under the organization of the Argentine Association of Biological Psychiatric (AAPB). The consensus statement aims to guide on diagnosis and treatment.

Wernicke-Kleist-Leonhard phenotypes of endogenous psychoses: a review of their validity
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While the ICD-DSM paradigm has been a major advance in clinical psychiatry, its usefulness for biological psychiatry is debated. By defining consensus-based disorders rather than empirically driven phenotypes, consensus classifications were not an implementation of the biomedical paradigm. In the field of endogenous psychoses, the Wernicke-Kleist-Leonhard (WKL) pathway has optimized the descriptions of 35 major phenotypes using common medical heuristics on lifelong diachronic observations. Regarding their construct validity, WKL phenotypes have good reliability and predictive and face validity. WKL phenotypes come with remarkable evidence for differential validity on age of onset, familiality, pregnancy complications, precipitating factors, and treatment response. Most impressive is the replicated separation of high- and low-familiality phenotypes. Created in the purest tradition of the biomedical paradigm, the WKL phenotypes deserve to be contrasted as credible alternatives with other approaches currently under discussion.
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[Acute and chronic psychoses with cenestopathies and/or hypochondriacal symptoms]. / Psicosis agudas y crónicas con cenestopatías y/o síntomas hipocondríacos.

Both cenestopathies (abnormal body sensations) and hypochondriac symptoms can occur in both acute and chronic psychotic disorders. The present article will brie?y describe some psychotic pictures that may accompanied with cenestopathies and/ or hypochondriacal symptoms. All descriptions will be illustrated with clinical examples to facilitate the understanding and delimitation of these diseases.

[Changes in the conceptualization of suicidal behavior throughout history: from antiquity to the DSM-5.] / Cambios en la conceptualización de la conducta suicida a lo largo de la historia: desde la antigüedad hasta el DSM-5.

Suicide is a universal and specific behavior of human beings which has been present throughout the history of mankind. However, throughout the ages social considerations about it have changed: the acceptance or punishment (and even how to carry out this punishment). These changes have relied upon the influence of different cultural factors. In this article, we review how the prevailing paradigms induced changes in the conceptualization of suicide.

The independent effects of child sexual abuse and impulsivity on lifetime suicide attempts among female patients.

Child sexual abuse (CSA) is a causal agent in many negative adulthood outcomes, including the risk for life-threatening behaviors such as suicide ideation and suicide attempts. Traumatic events such as CSA may pose risk in the healthy development of cognitive and emotional functioning during childhood. In fact, high impulsivity, a risk factor for suicidal behavior, is characteristic of CSA victims. The current study aims to understand the relations among CSA, impulsivity, and frequency of lifetime suicide attempts among a female patient sample admitted for suicidal behavior. Participants included 177 female patients between the ages of 18 and 63 years admitted at two hospitals in Buenos Aires, Argentina. Number of previous suicide attempts and CSA were assessed via structured interviews, while impulsivity was assessed with the Barratt Impulsiveness Scale (BIS-11). A model of structural equations was employed to evaluate the role of impulsivity in the relation between CSA and suicide attempts. CSA (ß=.18, p<.05) and impulsivity (ß=.24, p<.05) were associated with the number of previous suicide attempts. However, impulsivity was not significantly associated with CSA (ß=.09, p>.05). CSA and impulsivity are independently associated with lifetime suicide attempts among female patients with recent suicidal behavior.

Time Left for Intervention in the Suicidal Process in Borderline Personality Disorder.

The objective of this study was to measure the duration of the suicidal process among patients diagnosed with Borderline Personality Disorder (BPD). The sample included 110 female patients who met DSM-IV-TR criteria for BPD and were consecutively admitted after suicide-related behavior. A total of 63 patients (58%) reported that their suicidal process lasted 10 minutes or less. After being adjusted, the ß coefficient of impulsivity scales in women with a suicidal process ≤10 minutes was lower compared to those observed in women with >10 min (ß = -0.03, 95% CI = -0.06 = -0.01, p < 0.01). Suicidal patients with BPD can be divided into two groups; patients who report a suicidal process less than 10 minutes show a higher degree of impulsivity.

Types of borderline personality disorder (BPD) in patients admitted for suicide-related behavior.

Borderline personality disorder (BPD) is determined by the presence of any five of nine diagnostic criteria, leading patients with heterogeneous clinical features to be diagnosed under the same label without an individualized clinical and therapeutic approach. In response to this problem, Oldham proposed five types of BPD: affective, impulsive, aggressive, dependent and empty. The present study categorized a sample of BPD patients hospitalized due to suicide-related behavior according to Oldham's BPD proposed subtypes, and evaluated their clinical and demographic characteristics. Data were obtained from a sample of 93 female patients admitted to the « Dr. Braulio A. Moyano ¼ Neuropsychiatric Hospital following suicide-related behavior. A total of 87 patients were classified as affective (26%), impulsive (37%), aggressive (4%), dependent (29%), and empty (5%). Patients classified as dependent were significantly older at the time of first suicide-related behavior (p = 0.0008) and reported significantly less events of previous suicide-related behaviors (p = 0.03), while patients classified as impulsive reported significantly higher rates of drug use (p = 0.02). Dependent, impulsive and affective BPD types were observed most frequently in our sample. Findings are discussed specific to demographic and clinical implications of BPD patients reporting concurrent suicidal behavior.

[Patients hospitalized for suicidal ideation and suicide attempt in a Mental Health Hospital: Clinicodemographical features and 6-month follow-up]. / Pacientes hospitalizadas por ideación e intento de suicidio en un Hospital de Salud Mental: características clínico-demográficas y seguimiento a seis meses.

BACKGROUND: Suicide is an issue of high public health impact. In Argentina there are few published studies on suicide and suicide attempt. OBJECTIVE: To determine the percentage of hospitalizations caused by suicidal attempt or suicidal ideation in a Mental Health Hospital of the City of Buenos Aires, describe the clinical and demographic characteristics of these patients and to analyze the frequency of adverse events at a 6-month follow-up. METHODS: In the present study, baseline and follow-up data of an analytical, observational, prospective cohort study are used. RESULTS: Baseline data show that of all patients who entered the Emergency Department, 27% did so for ideation or suicide attempt. The most frequent diagnoses were: borderline personality disorder (41%), major depressive disorder (38%), bipolar disorder (20%) and schizophrenia (16%). The method most commonly used during the suicide attempt was drug poisoning. In half of the patients, the suicidal process was developed in less than 10 minutes. Monitoring data show that 22% of patients had a new attempted suicide and 34% had a readmission in a 6-month period. CONCLUSIONS: Together, these results describe the characteristics of suicide patients admitted to a Mental Health Hospital and show the low efficacy of interventions and the need to devise new strategies for the management of suicidal patients.

Systematic review of risk factors for suicide and suicide attempt among psychiatric patients in Latin America and Caribbean.

OBJECTIVE: To analyze published evidence from the Latin America and Caribbean (LAC) region pertaining to risk factors for completed suicide and suicide attempts among psychiatric populations. METHODS: Potential studies were identified through systematic electronic searches in MEDLINE and LILACS. Included studies were cohort, case-control, and cross-sectional designed investigations of psychiatric samples in which suicide or a suicide attempt was reported as an outcome and evaluated with some measure of impact (odds ratio, risk ratio, or hazard ratio). Methodological quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations. RESULTS: Of the 2 987 identified studies, a total of 17 studies were reviewed to determine potential suicidal risk factors. Eleven studies used a case-control design, five used a cross-sectional design, and only one study used a prospective-cohort design. The main risk factors for suicide attempts in LAC included major depressive disorder (MDD), family dysfunction, and prior suicide attempt, while the main risk factors for completed suicide were male gender and MDD. The methodological quality of most of the studies was low. CONCLUSIONS: This review provides evidence that the majority of relevant risk factors for suicide and suicide attempts in the LAC region are similar to those observed in Western societies but different from those reported in Eastern societies. Studies of higher methodological quality from the region are needed to support these results.

Systematic review of risk factors for suicide and suicide attempt among psychiatric patients in Latin America and Caribbean / Revisión sistemática de los factores de riesgo de suicidio e intento de suicidio entre los pacientes psiquiátricos de América Latina y el Caribe

OBJECTIVE: To analyze published evidence from the Latin America and Caribbean (LAC) region pertaining to risk factors for completed suicide and suicide attempts among psychiatric populations. METHODS: Potential studies were identified through systematic electronic searches in MEDLINE and LILACS. Included studies were cohort, case-control, and cross-sectional designed investigations of psychiatric samples in which suicide or a suicide attempt was reported as an outcome and evaluated with some measure of impact (odds ratio, risk ratio, or hazard ratio). Methodological quality was assessed using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) recommendations. RESULTS: Of the 2 987 identified studies, a total of 17 studies were reviewed to determine potential suicidal risk factors. Eleven studies used a case-control design, five used a cross-sectional design, and only one study used a prospective-cohort design. The main risk factors for suicide attempts in LAC included major depressive disorder (MDD), family dysfunction, and prior suicide attempt, while the main risk factors for completed suicide were male gender and MDD. The methodological quality of most of the studies was low. CONCLUSIONS: This review provides evidence that the majority of relevant risk factors for suicide and suicide attempts in the LAC region are similar to those observed in Western societies but different from those reported in Eastern societies. Studies of higher methodological quality from the region are needed to support these results.

OBJETIVO: Analizar los datos probatorios publicados de la región de América Latina y el Caribe (ALC) que fueran pertinentes a los factores de riesgo de suicidio consumado e intentos de suicidio entre las poblaciones psiquiátricas. MÉTODOS: Se seleccionaron los posibles estudios mediante búsquedas electrónicas sistemáticas en MEDLINE y LILACS. Se incluyeron estudios cuyos diseños de investigación fueran de cohortes, de casos y controles, o transversales de muestras psiquiátricas, y en los que el suicidio o un intento de suicidio se notificaran como un resultado, y se evaluaran mediante alguna medida de la repercusión (razón de posibilidades, razón de riesgos o razón de riesgos instantáneos). Se evaluó la calidad metodológica mediante el uso de las recomendaciones de la iniciativa de Fortalecimiento de la Notificación de los Estudios Observacionales en Epidemiología (STROBE, por sus siglas en inglés). RESULTADOS: Se analizaron 17 de los 2 987 estudios seleccionados con objeto de determinar los posibles factores de riesgo de suicidio. Once estudios usaron un diseño de casos y controles, cinco usaron un diseño transversal, y un único estudio usó un diseño de cohortes prospectivo. Los principales factores de riesgo de intento de suicidio en ALC fueron el trastorno depresivo mayor (TDM), la disfunción familiar y el intento de suicidio previo, mientras que los principales factores de riesgo de suicidio consumado fueron el sexo masculino y el TDM. La mayor parte de los estudios mostraron una mala calidad metodológica. CONCLUSIONES: Esta revisión aporta datos probatorios de que la mayor parte de los factores de riesgo pertinentes al suicidio y los intentos de suicidio en la región de ALC son similares a los observados en las sociedades occidentales pero diferentes a los notificados en las sociedades orientales. Se necesitan estudios regionales de mayor calidad metodológica para apoyar estos resultados.

[Historical and conceptual evolution of non-schizophrenic psychotic disorders in DSM]. / Evolución histórica y conceptual de los trastornos psicóticos no esquizofrénicos en los DSM.

After firmly established the "kraepelinean dichotomy" (dementia praecox - manic-depressive insanity), classical psychiatry began to describe a group of psychotic disorders which did not fit in any of these main diagnoses. Many of these clinical pictures where incorporated to the DSM and underwent several changes throughout the successive editions of the American manual. This article aims to make a historical and conceptual overview of this group of non-schizophrenic psychotic disorders accompanying schizophrenia in the "Schizophrenia spectrum and other psychotic disorders" chapter of DSM-5.

Evolución histórica y conceptual de los trastornos psicóticos no esquizofrénicos en los DSM / [Historical and conceptual evolution of non-schizophrenic psychotic disorders in DSM].

After firmly established the "kraepelinean dichotomy" (dementia praecox - manic-depressive insanity), classical psychiatry began to describe a group of psychotic disorders which did not fit in any of these main diagnoses. Many of these clinical pictures where incorporated to the DSM and underwent several changes throughout the successive editions of the American manual. This article aims to make a historical and conceptual overview of this group of non-schizophrenic psychotic disorders accompanying schizophrenia in the "Schizophrenia spectrum and other psychotic disorders" chapter of DSM-5.