Successful Clozapine Rechallenge After Clozapine-Induced Severe Anemia: A Case Report.

INTRODUCTION: Clozapine, a second-generation antipsychotic (SGA), is considered the gold standard medication to treat patients with treatment-resistant schizophrenia (TRS). Despite its efficacy, clozapine is associated with adverse effects, notably neutropenia and agranulocytosis. Other hematological adverse effects are less common. Severe anemia is a rare adverse effect seldom reported in the literature and is typically associated with pure red cell aplasia (PRCA). Nevertheless, the benefits of clozapine in managing TRS make rechallenge a reasonable option. CASE REPORT: We present the case of a 35-year-old man with TRS, resistant to previous antipsychotics, who experienced severe anemia during clozapine treatment. An investigation for clozapine-induced anemia revealed PRCA on myelogram. After discontinuing clozapine, the patient's hemoglobin levels recovered. Subsequent treatments with olanzapine, zuclopenthixol, and aripiprazole proved ineffective, leading us to consider a clozapine rechallenge. The rechallenge, monitored for 58 days, resulted in improved psychiatric symptoms and stable hemoglobin levels. The patient remained stable during 6 months of follow-up, with no hematological changes. DISCUSSION: PRCA is a very rare adverse effect of clozapine. The cause of drug-induced PRCA is still unknown; for clozapine, there are no studies. Rechallenge after a severe and rare adverse effect is a complex decision. This case is the first to report a successful clozapine rechallenge following severe anemia without other blood dyscrasias, emphasizing the imperative need for close monitoring during the rechallenge process. Further study is warranted to understand the predictive factors for a successful outcome in clozapine rechallenges.

Simplifying the human serum proteome for discriminating patients with bipolar disorder of other psychiatry conditions.

PURPOSE: An exploratory analysis using proteomic strategies in blood serum of patients with bipolar disorder (BD), and with other psychiatric conditions such as Schizophrenia (SCZ), can provide a better understanding of this disorder, as well as their discrimination based on their proteomic profile. METHODS: The proteomic profile of blood serum samples obtained from patients with BD using lithium or other drugs (N=14), healthy controls, including non-family (HCNF; N=3) and family (HCF; N=9), patients with schizophrenia (SCZ; N=23), and patients using lithium for other psychiatric conditions (OD; N=4) were compared. Four methods for simplifying the serum samples proteome were evaluated for both removing the most abundant proteins and for enriching those of lower-abundance: protein depletion with acetonitrile (ACN), dithiothreitol (DTT), sequential depletion using DTT and ACN, and protein equalization using commercial ProteoMiner® kit (PM). For proteomic evaluation, 2-D DIGE and nanoLC-MS/MS analysis were employed. RESULTS: PM method was the best strategy for removing proteins of high abundance. Through 2-D DIGE gel image comparison, 37 protein spots were found differentially abundant (p<0.05, Student's t-test), which exhibited ≥2.0-fold change of the average value of normalized spot intensities in the serum of SCZ, BD and OD patients compared to subject controls (HCF and HCNF). From these spots detected, 13 different proteins were identified: ApoA1, ApoE, ApoC3, ApoA4, Samp, SerpinA1, TTR, IgK, Alb, VTN, TR, C4A and C4B. CONCLUSIONS: Proteomic analysis allowed the discrimination of patients with BD from patients with other mental disorders, such as SCZ. The findings in this exploratory study may also contribute for better understanding the pathophysiology of these disorders and finding potential serum biomarkers for these conditions.

Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital.

OBJECTIVE: To describe the sociodemographic and clinical profile of patients who underwent electroconvulsive therapy (ECT) at a university general hospital. METHOD: In this retrospective study, records from all patients undergoing ECT between January 1988 and January 2008 at the psychiatric unit of the general hospital of Universidade Estadual de Campinas (UNICAMP) were reviewed. Telephone contact was made with patients/relatives to collect follow-up data. RESULTS: A total of 200 charts were reviewed. The majority of patients were women, with a mean age of 39 years, and history of psychiatric hospitalization. The main indications for ECT were depression and catatonia. Complications were observed in less than half of the cases, and most were temporary and not severe. There was a good psychiatric outcome for 89.7% of the patients, especially for catatonic patients (100%, p = 0.02). Thirty-four percent of the cases were later contacted by telephone calls, at a mean of 8.5 years between the procedure and the contact. Among these, three (1.5%) reported persistent memory disorders and 73% considered ECT a good treatment. CONCLUSION: ECT has been performed according to international guidelines. In the vast majority of cases, undesirable effects were temporary and not severe. Response to ECT was positive in most cases, particularly in catatonic patients.

Twenty years of electroconvulsive therapy in a psychiatric unit at a university general hospital / Vinte anos de eletroconvulsoterapia em enfermaria psiquiátrica de hospital geral universitário

Objective: To describe the sociodemographic and clinical profile of patients who underwent electroconvulsive therapy (ECT) at a university general hospital. Method: In this retrospective study, records from all patients undergoing ECT between January 1988 and January 2008 at the psychiatric unit of the general hospital of Universidade Estadual de Campinas (UNICAMP) were reviewed. Telephone contact was made with patients/relatives to collect follow-up data. Results: A total of 200 charts were reviewed. The majority of patients were women, with a mean age of 39 years, and history of psychiatric hospitalization. The main indications for ECT were depression and catatonia. Complications were observed in less than half of the cases, and most were temporary and not severe. There was a good psychiatric outcome for 89.7% of the patients, especially for catatonic patients (100%, p = 0.02). Thirty-four percent of the cases were later contacted by telephone calls, at a mean of 8.5 years between the procedure and the contact. Among these, three (1.5%) reported persistent memory disorders and 73% considered ECT a good treatment. Conclusion: ECT has been performed according to international guidelines. In the vast majority of cases, undesirable effects were temporary and not severe. Response to ECT was positive in most cases, particularly in catatonic patients.

Objetivo: Descrever o perfil sociodemográfico e clínico de pacientes submetidos a eletroconvulsoterapia (ECT) em um hospital geral universitário. Método: Neste estudo retrospectivo, foram revisados os prontuários de todos os pacientes submetidos a ECT entre janeiro de 1988 e janeiro de 2008 na unidade psiquiátrica do hospital geral da Universidade Estadual de Campinas (UNICAMP). Os pacientes/familiares foram contatados por telefone para a coleta de dados de seguimento. Resultados: Um total de 200 prontuários foram revisados. A maioria dos pacientes era do sexo feminino, com uma idade média de 39 anos e história de hospitalização psiquiátrica prévia. As principais indicações para ECT foram depressão e catatonia. Complicações foram observadas em menos de metade dos casos, e a maioria delas teve caráter temporário e não grave. Houve resultado psiquiátrico favorável em 89,7% dos pacientes, especialmente os catatônicos (100%, p = 0,02). Trinta e nove por cento dos casos foram contatados por telefone, a uma média de 8,5 anos decorridos entre o procedimento e o contato. Entre estes, três (1,5%) relataram transtornos amnésticos persistentes e 73% consideraram a ECT um bom tratamento. Conclusão: A ECT foi realizada de acordo com diretrizes internacionais. Na grande maioria dos casos, efeitos indesejáveis foram temporários e não graves. A resposta à ECT foi positiva na maioria dos casos, especialmente em pacientes catatônicos.

Apolipoprotein A-I as a candidate serum marker for the response to lithium treatment in bipolar disorder.

The molecular basis of bipolar disorder (BD) is still unknown as is the mechanism through which lithium, the therapy of choice, exerts its effects in treatment of BD. So far, no biomarkers exist to facilitate diagnosis of BD or treatment evaluation. To investigate whether BD and its treatment with lithium leaves a characteristic signature in the serum proteome, we used SELDI-TOF MS to analyze individual serum samples from BD patients treated with lithium (BD-plus-Li, n=15) or other drugs (BD-minus-Li, n=10) and from healthy controls (n=15). Interestingly, features of 28 kDa (one peak) and 14 kDa (three peaks) showed a decreased level in the BD-minus-Li group and a level restored to that of the control group in the BD-plus-Li group. To reveal the identity of these features, we subjected pooled serum samples from both BD groups to the 2-D DIGE technology and identified 28 kDa apolipoprotein A-I (apo A-I) and three 14 kDa fragments thereof as upregulated in the BD-plus-Li group. Immunoturbidimetry, a routine clinical assay, verified the characteristic apo A-I signature in individual serum samples. In conclusion, we propose apo A-I as a candidate marker that can visualize response to lithium treatment at the serum protein level.

Metabolic profiling of human blood serum from treated patients with bipolar disorder employing 1H NMR spectroscopy and chemometrics.

Metabolic profiling employing hydrogen nuclear magnetic resonance (1H NMR) spectroscopy and chemometric analysis of human blood serum samples taken from the control group (n = 25) and patients with bipolar disorder (n = 25) was performed to identify molecular changes related to the disorder and to different drug treatments: lithium (n = 15) versus other medications (n = 10). This strategy showed significant potential for exploring pathophysiological and toxicological features involved in bipolar disorder. The investigated groups (control and patients with bipolar disorder under different treatments) could be distinguished according to their metabolic profiles, and the main differential metabolites found were lipids, lipid-metabolism-related molecules (acetate, choline, and myo-inositol), and some key amino acids (glutamate, glutamine). Our results suggest that some of the 24 identified metabolites may be linked to lithium- and other-medication-provoked metabolic changes or may even be directly related to the disorder. Thus, these findings may contribute to paving the way for future studies aiming at identifying potential biomarkers for bipolar disorder.

Avaliação qualitativa sobre o que os psiquiatras brasileiros esperam das classificações diagnósticas / A qualitative analysis on what Brazilian psychiatrists expect from current diagnostic classifications

Introdução: Pretende-se analisar o perfil de respostas qualitativas a um questionário padronizado anônimo, com itens abertos e fechados, sobre a percepção dos psiquiatras brasileiros acerca do uso dos sistemas diagnósticos multiaxiais CID-10 e DSM-IV e de suas expectativas quanto às próximas revisões (CID-11 e DSM-V). Método: O questionário, elaborado por Graham Mellsop (Nova Zelândia), foi traduzido e enviado para 1.050 psiquiatras afiliados à Associação Brasileira de Psiquiatria. Resultados: Retornaram 160 questionários (15,2%). Nestes, 71,1% das questões abertas foram respondidas. As principais qualidades julgadas necessárias ou desejadas em uma classificação psiquiátrica foram: simplicidade, clareza de critérios, objetividade, compreensibilidade, confiabilidade e facilidade de uso. O eixo I da CID-10 foi citado como o mais utilizado pelo caráter instrumental e pelo fato de ser a classificação oficial, inclusive para fins burocráticos e legais. O DSM-IV também é bastante utilizado no cotidiano, sobretudo para ensino e pesquisa, por psiquiatras com afiliações acadêmicas. O uso menos frequente de sistemas multiaxiais foi justificado pela falta de treino e de familiaridade, pela sobrecarga de informações e pelo fato de não serem obrigatórios. Avaliou-se que algumas categorias diagnósticas, entre outras, devem ser revistas, como: retardo mental, transtornos alimentares, de personalidade, do sono, da infância e adolescência, quadros ansiosos, afetivos, esquizoafetivos. Conclusão: O material fornece um panorama sobre as opiniões e expectativas dos psiquiatras a respeito dos instrumentos diagnósticos dos quais se servem ativamente em sua prática diária e cujas revisões estão em pleno processo de elaboração.

Introduction: The objective of the present study was to analyze the qualitative answers of an anonymous standardized survey including qualitative and quantitative questions about the Brazilian psychiatrists’ perceptions on their use of the multiaxial diagnostic systems ICD-10 and DSM-IV and about their expectations regarding future revisions of these classifications (ICD-11 and DSM-V). Method: The questionnaire, elaborated by Graham Mellsop (New Zealand), was translated into Portuguese and sent through mail to 1,050 psychiatrists affiliated to the Brazilian Psychiatry Association. The quantitative analysis is presented elsewhere. Results: One hundred and sixty questionnaires returned (15.2%). From these, 71.1% of the open questions where answered. The most needed and/or desirable qualities in a psychiatric classification were found to be: simplicity, clarity of criteria, objectivity, comprehensibility, reliability, and ease to use. Axis I of the ICD-10 was reported to be the most used due to its instrumental character in addition to being the official classification also for legal and bureaucratic purposes. The DSM-IV was also used in the everyday practice, mostly for education and research purposes, by psychiatrists with academic affiliations. The less frequent use of the multiaxial systems was explained by the lack of training and familiarity, the overload of information and by the fact they are not mandatory. Based on the respondents’ answers, we concluded that some diagnostic categories must be revised, such as: mental retardation, eating disorders, personality disorders, sleeping disorders, child and adolescent disorders, affective, and schizoaffective disorders. Conclusion: This material offers a systematic overview of the psychiatrists’ opinions and expectations concerning the diagnostic instruments used in their daily practice.

Counseling brazilian undergraduate students: 17 years of a campus mental health service.

OBJECTIVE: The authors reviewed demographic and clinical characteristics of undergraduates at a Brazilian public university (UNICAMP) who visited the campus mental health service (SAPPE) and compared their demographics with those from all undergraduate students enrolled in the university. PARTICIPANTS: The authors looked at data from all undergraduates who sought counseling or mental health care at SAPPE over a 17-year period (N = 2,203; 1987-2004). METHODS: They obtained this information from clinical charts and a UNICAMP database. RESULTS: Women, students from other Brazilian states, students living in the campus residence hall, and students whose main source of income was a scholarship were overrepresented. Female student-clients complained about family conflicts more frequently than did their male counterparts, and male student-clients reported concern about poor academic performance more frequently than did their female counterparts. CONCLUSIONS: Sex, living in a university residential facility, and reliance on a scholarship grant were predictive of undergraduates' mental health-seeking behavior and pattern of complaints.

Demographics and complaints of university students who sought help at a campus mental health service between 1987 and 2004.

CONTEXT AND OBJECTIVE: Client characterization is an important step in evaluating the services offered by campus counseling and mental health centers and in their further planning and development. The objectives here were to describe reported complaints and demographics among students who sought counseling/mental healthcare at a Brazilian campus mental health service over a 17-year period and to compare these characteristics with those of the general university student body. DESIGN AND SETTING: Retrospective study at the Psychological and Psychiatric Service for Students (SAPPE), Universidade Estadual de Campinas (Unicamp). METHODS: The participants were all of the 2,194 students who sought counseling/mental health care at SAPPE from 1987 to 2004. Information was obtained from clients clinical charts. Unicamps database was consulted for general information on its students. RESULTS: The findings indicated overrepresentation, among the clients, of undergraduates, female students, students from Brazilian states other than São Paulo, students living in the campus residence hall and those whose main source of income was a scholarship grant. We also found overrepresentation of Humanities and Arts students among the clients. The most frequently reported complaints were difficulties in interpersonal relationships, family conflicts and poor academic performance. CONCLUSION: Course level (undergraduate or postgraduate), study field, living in a university residential facility and reliance on a scholarship grant were found to influence the behavior of seeking mental health counseling among Brazilian university students in this study. Course level was found to influence the pattern of complaints reported at first contact with the mental health service.

Demographics and complaints of university students who sought help at a campus mental health service between 1987 and 2004

CONTEXT AND OBJECTIVE: Client characterization is an important step in evaluating the services offered by campus counseling and mental health centers and in their further planning and development. The objectives here were to describe reported complaints and demographics among students who sought counseling/mental healthcare at a Brazilian campus mental health service over a 17-year period and to compare these characteristics with those of the general university student body. DESIGN AND SETTING: Retrospective study at the Psychological and Psychiatric Service for Students (SAPPE), Universidade Estadual de Campinas (Unicamp). METHODS: The participants were all of the 2,194 students who sought counseling/mental health care at SAPPE from 1987 to 2004. Information was obtained from clients’ clinical charts. Unicamp’s database was consulted for general information on its students. RESULTS: The findings indicated overrepresentation, among the clients, of undergraduates, female students, students from Brazilian states other than São Paulo, students living in the campus residence hall and those whose main source of income was a scholarship grant. We also found overrepresentation of Humanities and Arts students among the clients. The most frequently reported complaints were difficulties in interpersonal relationships, family conflicts and poor academic performance. CONCLUSION: Course level (undergraduate or postgraduate), study field, living in a university residential facility and reliance on a scholarship grant were found to influence the behavior of seeking mental health counseling among Brazilian university students in this study. Course level was found to influence the pattern of complaints reported at first contact with the mental health service.

CONTEXTO E OBJETIVO: A caracterização dos pacientes é uma etapa fundamental para a avaliação e aprimoramento dos serviços de saúde mental para estudantes universitários. Os objetivos deste estudo foram descrever as características sócio-demográficas e as queixas referidas pelos estudantes de uma universidade pública brasileira que procuraram atendimento num serviço de saúde mental para universitários por um período de 17 anos e compará-los com a totalidade dos estudantes dessa universidade. TIPO DE ESTUDO E LOCAL: Estudo retrospectivo realizado no Serviço de Assistência Psicológica e Psiquiátrica ao Estudante (SAPPE) da Universidade Estadual de Campinas (Unicamp). MÉTODO: Os sujeitos foram 2.194 estudantes que procuraram atendimento em saúde mental no SAPPE no período de 1987 a 2004. Os dados foram obtidos a partir de seus prontuários. O banco de dados da Unicamp foi consultado para a obtenção das informações sobre os estudantes da universidade como um todo. RESULTADOS: Entre os alunos que procuraram atendimento encontramos uma sobre-representação de estudantes de graduação, do sexo feminino, procedentes de outros estados brasileiros que não o Estado de São Paulo, que moravam na moradia universitária, que tinham bolsas de auxílio como principal fonte de renda e das áreas de Humanas e Artes. As queixas mais relatadas foram: dificuldades no relacionamento interpessoal, conflitos familiares e desempenho acadêmico insatisfatório. CONCLUSÃO: O nível do curso (graduação ou pós-graduação), a área do curso, ser residente na moradia universitária e possuir bolsa de auxílio foram variáveis que influenciaram a procura de atendimento em saúde mental dos estudantes universitários brasileiros avaliados. O nível do curso influenciou o tipo de queixa referida no primeiro contato com o serviço de saúde mental.

Dementia and functional decline in patients with Parkinson's disease.

Functional decline in Parkinson's disease (PD), characterized by reduced ability to carry out activities of daily living, usually results from typical motor impairment and may be aggravated by concomitant cognitive impairment. OBJECTIVE: To compare the functional decline in Parkinson's disease between patients with dementia and cognitively preserved patients. METHODS: From an original sample composed of 50 patients with a clinical diagnosis of idiopathic PD seen in a consecutive series, 33 non-depressed patients were selected comprising 13 with dementia and 20 cognitively preserved individuals. All patients enrolled in this study were drawn from a public outpatient clinic, specialized in movement disorders. The clinical stage of PD was determined by the Hoehn & Yahr scale, and the functional capacity was verified using the Unified Parkinson's Disease Rating Scale UPDRS ADL (subscale II: activities of daily living) and the Schwab & England scale. The two last scales measure the functional degree of independence in activities of daily living. The neuropsychological assessment was performed using The Cambridge Examination for Mental Disorders of the Elderly - CAMCOG, Cognitive Section and the Stroop Color Word Test. RESULTS: As expected, in comparison with cognitively preserved patients, the group with dementia presented significantly lower scores throughout the neuropsychological evaluation. The patients with dementia were found to have a longer period of disease, a more advanced clinical staging according to the Hoehn & Yahr, and greater functional decline according both to the UPDRS ADL and Schwab & England, with statistically significant difference between the groups. CONCLUSION: Patients with dementia were at a more advanced clinical stage of Parkinson's disease and evidenced greater functional decline in comparison with patients without dementia.

O declínio funcional na doença de Parkinson (DP), caracterizado pela redução da capacidade para as atividades de vida diária, usualmente resulta do comprometimento motor típico, podendo ainda ser agravado pelo declínio cognitivo concomitante. OBJETIVOS: Comparar o declínio funcional de pacientes com e sem demência na doença de Parkinson. MÉTODOS: De uma amostra original composta por 50 pacientes com diagnóstico clínico de DP idiopática, avaliados em uma série consecutiva, foram selecionados 33 pacientes não deprimidos, sendo 13 com demência e 20 cognitivamente preservados. Todos os pacientes eram acompanhados em um ambulatório público especializado em distúrbios do movimento. Aplicamos a Unified Parkinson's Disease Rating Scale ­ UPDRS (sub-escala II: atividades de vida diária ­ UPDRS ADL), a escala Schwab & England, a escala Hoehn & Yahr, o Cambridge Examination for Mental Disorders of the Elderly ­ Seção Cognitiva (CAMCOG) e o Stroop Color Word Test. RESULTADOS: Como esperado, em comparação com pacientes cognitivamente preservados, o grupo com demência apresentou escores menores na avaliação neuropsicológica. Os pacientes com demência tinham, também, um tempo maior de doença, pertenciam a um estágio clínico mais avançado segundo a Hoehn & Yahr, e seu declínio funcional, segundo a UPDRS ADL e a Schwab & England, mostrava-se mais acentuado, com diferença estatisticamente significativa entre os grupos. CONCLUSÃO: Os pacientes com demência encontravam-se em um estágio clínico mais avançado da doença e seu declínio funcional mostrou-se mais acentuado em comparação com os pacientes sem demência.

Inter-rater reliability and factor analysis of the Brazilian version of the Schedule for the Assessment of Insight: Expanded Version (SAI-E)

OBJECTIVES: The Schedule for the Assessment of Insight - Expanded Version consists of 11 items that encompass: awareness of having a mental illness, ability to rename psychotic phenomena as abnormal, and compliance with treatment. The objective of the study was to evaluate the inter-rater reliability and to study the factorial structure of the Brazilian version of the instrument. METHOD: The Brazilian version of the Schedule for the Assessment of Insight - Expanded Version was used for the assessment of insight of 109 psychotic inpatients, 60 of whom had the interview tape-recorded in order to be scored by an independent evaluator. Intraclass correlation coefficient (ICC) was adopted as the inter-rater reliability coefficient. In the factor analysis, principal components analysis and Varimax rotation were adopted. RESULTS: Inter-rater reliability coefficients from good to excellent were found for the individual items of the Schedule for the Assessment of Insight - Expanded Version with ICC values ranging from 0.54 to 0.82. Regarding the total score, inter-rater reliability was excellent, with ICC = 0.90. A factorial structure similar to the one obtained by the original version of the Schedule for the Assessment of Insight - Expanded Version was found, with 3 factors accounting for 71.72 percent of variance. CONCLUSION: In the Brazilian context, the Schedule for the Assessment of Insight - Expanded Version presented good inter-rater reliability and factorial structure compatible to the insight dimensions that are intended to be evaluated.

OBJETIVOS: O Schedule for the Assessment of Insight - Expanded Version é constituído por 11 itens que abordam: reconhecimento de se ter um transtorno mental, capacidade de renomear fenômenos psicóticos como anormais e adesão ao tratamento. O objetivo do estudo foi avaliar a confiabilidade entre avaliadores e estudar a estrutura fatorial da versão brasileira do Schedule for the Assessment of Insight - Expanded Version. MÉTODO: A versão brasileira do Schedule for the Assessment of Insight - Expanded Version foi utilizada na avaliação de 109 pacientes psicóticos internados, dos quais 60 tiveram a entrevista gravada para atribuição de escores por avaliador independente. O coeficiente de correlação intraclasse (ICC) foi utilizado na avaliação da confiabilidade entre avaliadores. Para a análise fatorial foram adotadas análise de componentes principais e rotação varimax. RESULTADOS: A confiabilidade entre avaliadores para os itens do Schedule for the Assessment of Insight - Expanded Version encontrada esteve entre boa e excelente, com ICC variando de 0,54 a 0,82; para o escore total foi excelente, com ICC = 0,90. Uma estrutura fatorial semelhante à obtida para a versão original do Schedule for the Assessment of Insight - Expanded Version foi encontrada, com três fatores explicando 71,72 por cento da variação. CONCLUSÃO: No contexto brasileiro, o Schedule for the Assessment of Insight - Expanded Version apresentou boa confiabilidade entre avaliadores e estrutura fatorial compatível com as dimensões do insight que pretende avaliar.

Inter-rater reliability and factor analysis of the Brazilian version of the Schedule for the Assessment of Insight: Expanded Version (SAI-E).

OBJECTIVES: The Schedule for the Assessment of Insight - Expanded Version consists of 11 items that encompass: awareness of having a mental illness, ability to rename psychotic phenomena as abnormal, and compliance with treatment. The objective of the study was to evaluate the inter-rater reliability and to study the factorial structure of the Brazilian version of the instrument. METHOD: The Brazilian version of the Schedule for the Assessment of Insight - Expanded Version was used for the assessment of insight of 109 psychotic inpatients, 60 of whom had the interview tape-recorded in order to be scored by an independent evaluator. Intraclass correlation coefficient (ICC) was adopted as the inter-rater reliability coefficient. In the factor analysis, principal components analysis and Varimax rotation were adopted. RESULTS: Inter-rater reliability coefficients from good to excellent were found for the individual items of the Schedule for the Assessment of Insight - Expanded Version with ICC values ranging from 0.54 to 0.82. Regarding the total score, inter-rater reliability was excellent, with ICC = 0.90. A factorial structure similar to the one obtained by the original version of the Schedule for the Assessment of Insight - Expanded Version was found, with 3 factors accounting for 71.72% of variance. CONCLUSION: In the Brazilian context, the Schedule for the Assessment of Insight - Expanded Version presented good inter-rater reliability and factorial structure compatible to the insight dimensions that are intended to be evaluated.

O que os psiquiatras brasileiros esperam das classificações diagnósticas? / What do Brazilian psychiatrists want from diagnostic classifications?

OBJETIVO: Realizou-se um levantamento postal anônimo com psiquiatras brasileiros afiliados à Associação Brasileira de Psiquiatria (ABP) sobre uso, percepção em termos de utilidade clínica dos sistemas diagnósticos multiaxiais CID-10 e DSM-IV e, ainda, expectativas sobre as próximas revisões. MÉTODOS: A carta-convite, o questionário padronizado e um envelope selado foram enviados para 1.050 dos 3.062 psiquiatras associados da ABP, selecionados de forma randomizada. Em virtude da taxa relativamente baixa de retorno: 160 respostas (15,2 por cento), não se pode afirmar que a amostra obtida seja representativa. resultados: Os principais resultados mostraram que, entre os respondentes, a CID-10 é o sistema diagnóstico mais utilizado, sobretudo seu eixo clínico. O DSM-IV também é amplamente empregado, principalmente os eixos I e II. A principal característica esperada de um sistema classificatório foi a confiabilidade para comunicação. As classificações são vistas como instrumentos a ser manejados pelos psiquiatras e, em menor proporção, por outros membros de equipes multidisciplinares de saúde mental. Os atuais sistemas foram considerados confiáveis para o uso transcultural no contexto brasileiro. Em relação às expectativas quanto aos futuros sistemas, os psiquiatras preferem classificações com menos de 100 rubricas diagnósticas e dividem-se entre os que acham que estas devam expressar preferencialmente causa/patogênese dos transtornos mentais e aqueles que esperam que tais categorias, sobretudo, sejam construídas de modo a subsidiar o planejamento terapêutico. CONCLUSÕES: Os sistemas diagnósticos desempenham um importante papel na prática psiquiátrica cotidiana dos psiquiatras respondentes. As opiniões dos psiquiatras brasileiros parecem refletir bem algumas controvérsias existentes acerca de questões nosográficas decisivas.

OBJECTIVE: An anonymous mail survey was carried out with Brazilian psychiatrists affiliated with Brazilian Psychiatric Association (ABP). A structured questionnaire was employed to assess use and perceived utility of current diagnostic classifications (ICD-10 and DSM-IV), as well as their expectations about the future revisions. METHODS: From the mailing list provided by ABP with 3,062 names of affiliated Brazilian psychiatrists, 1,050 were randomly selected to receive the questionnaire, along with a stamped, return address envelope. From the sample of 1,050, 160 completed questionnaires were returned, which corresponds to the following rate of response: 15.2 percent. No claims are made about the representativeness of the sample. RESULTS: It was found that the ICD-10 is the most frequently used system, especially its clinical axis. The DSM-IV's axes I and II are often used as well. For this sample the most important purpose of a classification is to ensure reliable inter-clinician communication. Classifications are seen as tools for psychiatric use and, to a lesser extent, for the use of a multidisciplinary team. Current diagnostic systems are perceived as reliable for cross-cultural use in our context. Regarding expectations about the future revisions, Brazilian psychiatrists prefer simpler classifications, with less than 100 diagnostic labels. They split, however, about having separate systems to account for cause/pathogenesis and to inform treat ment plans or a single classification, with many compromises, to convey information concerning causes, prognosis and treatment decisions. CONCLUSIONS: Classificatory systems play an important role in everyday psychiatric clinical practice in this sample of psychiatrists. Brazilian psychiasystems. trists' opinions seem to reflect well existing controversies regarding some key nosographic issues.

Delírio: características psicopatológicas e dimensões comportamentais em amostras clínicas / Delusion: psychopathological characteristics and behavioral dimensions in clinical samples

O delírio é um dos fenômeno mais centrais e intrigantes da psicopatologia. O conhecimento de seus mecanismos etiológicos, assim como de suas implicações clínicas, ainda é insatisfatório. Dá-se ênfase atualmente às chamadas dimensões do delírio (grau de convicção, extensão, bizarrice, desorganização, pressão, resposta afetiva e atuação ou comportamento desviante). Este estudo visou a avaliar tais dimensões, além das características definidas por jaspers em 24 pacientes intensamente delirantes. Além disso, compararam-se características demográficas, clínicas e cognitivas de pacientes delirantes (n = 83) com as de pacientes não delirantes (n = 111). Os pacientes delirantes apresentaram um melhor desempenho cognitivo que os não-delirantes. O comportamento desviante em função do delírio apresentou-se relacionado à resposta afetiva e ao grau de convicção, e este, por sua vez, relacionou-se à resposta afetiva ao delírio.

Mania e gravidez: implicações para o tratamento farmacológico e proposta de manejo / Mania and pregnancy: issues related to pharmacologic treatment and management proposal

O tratamento de doenças psiquiátricas na gravidez é complexo, implicando decisões clínicas difíceis, sem contar-se com dados da literatura que embasem aplamente estas decisões. O transtorno afetivo bipolar é comum em mulheres em idade fértil, e há alto risco de ocorrência de manifestações clínicas na gravidez e no período pós-parto. Os autores revisam o conhecimento atual sobre o uso de psicotrópicos para episódio maníaco na gravidez e o efeito no desenvolvimento fetal e da criança. Enfatizam que, hoje, o uso de psicotrópicos na gravidez é apropriado em muitas situações clínicas, mas nenhuma decisão é completamente isenta de risco. Também apresentam uma proposta de manejo da doença em relação ao uso de psicotrópicos na gravidez, para pacientes com transtorno bipolar, e para aquelas que desejam engravidar.

Hospital-dia em psiquiatria: revisåo dos últimos cinco anos da literatura / Day hospital in psychiatry: a review of the last five years literature

Os autores revisam a literatura psiquiatríca recente (últimos cinco anos) a respeito da hospitalizaçäo parcial, e especialmente, de hospital-dia. Uma discussäo crítica da mesma é realizada enfatizando diversos aspectos: definiçäo em termos conceituais, possíveis modelos organizacionais, populaçäo alvo, e princípios do atendimento. Consideraçöes de ordem metodológica säo formuladas com o intuito de explicar a impossibilidade de generalizaçäo dos resultados obtidos pela maioria dos estudos mencionados. Além disso, säo examinadas as incidências desses dados sobre a atual situaçäo brasileira de atençäo à saúde mental, particularmente em questöes de planejamento. Finalmente, os autores, tendo em conta ainda a experiência relatada em outro texto, apontam: 1- o risco de subutilizaçäo de um hospital-dia em nosso meio face à arraigada cultura de internaçäo presente; 2- a necessidade do hospital-dia estar integrado a um sistema organizado de atençäo; e 3- alguns requisitos para um funcionamento eficaz do hospital-dia, sendo estes distintos conforme a populaçäo-alvo predominante seja constituída de pacientes agudos ou crônicos