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.

Third Argentine Consensus statement on management Bipolar Disorders. Section3: Bipolar Disorder in the context of special situations / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Tercera parte: Manejo de los Trastornos Bipolares en el contexto de situaciones especiales.

This document constitutes the third and last part of the Third Argentine Consensus on the Management of Bipolar Disorders carried out by the Argentine Association of Biological Psychiatry (AAPB). Continuing with the initial objective, this section of the Consensus on the Management of Bipolar Disorders is focused on the management of bipolar disorders in special populations. This section constitutes a comprehensive review and expert consideration of the scientific evidence on: a) the management of bipolar disorders in treatment-resistant patients; b) the management of bipolar disorder in childhood and adolescence; c) the management of bipolar disorders in women during their perinatal period and, d) the management of bipolar disorders in older adults.

Este documento constituye la tercera y última parte del Tercer Consenso Argentino sobre el Manejo de los Trastornos Bipolares llevada a cabo por la Asociación Argentina de Psiquiatría Biológica (AAPB). Siguiendo con el objetivo propuesto por el comité de expertos, en la actual versión del Consenso sobre el manejo de los trastornos bipolares, esta sección está enfocada al abordaje de los Trastornos Bipolares en situaciones especiales. Esto configura una revisión exhaustiva de la evidencia científica  sobre: a) el manejo de los trastornos bipolares en pacientes resistentes al tratamiento, b) el manejo de los trastornos bipolares en la mujer en el período perinatal, c) el manejo del trastorno bipolar en la etapa infantojuvenil y d) el manejo de los trastornos bipolares en los adultos mayores.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 B / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Segunda Parte B.

This document constitutes the second section B of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The scope of this section is to provide therapeutic recommendations for managing bipolar disorders in adults, (i) acute mania (ii) bipolar depression (iii) mixed stated (iv) suicidality and (vi) psychological interventions. In addition, the current manuscript outlines the assessment and management of side effects of pharmacotherapeutic treatments.

Este documento constituye la segunda parte B del Tercer Consenso Argentino sobre el Manejo de los Trastornos Bipolares llevada a cabo por la Asociación Argentina de Psiquiatría Biológica (AAPB). Siguiendo con el direccionamiento iniciado en el parte 2A sobre el tratamiento integral de los trastornos bipolares, esta sección se ha enfocado en sintetizar la evidencia más actualizada sobre abordajes terapéuticos para pacientes adultos. El alcance de esta sección es proporcionar recomendaciones terapéuticas para el manejo de los trastornos bipolares en adultos, (i) manía aguda, (ii) depresión bipolar, (iii) estado mixto, (iv) el suicidio en el trastorno bipolar, (v) intervenciones psicológicas. Además, el presente manuscrito aborda la evaluación y el manejo de los efectos secundarios de los tratamientos farmacoterapéuticos.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 A: Comprehensive treatment of the bipolar disorders in adults / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Segunda Parte A: Tratamiento integral de los trastornos bipolares en el adulto.

This document constitutes the second section A of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The aim of this section (2A) is to provide therapeutic recommendations for managing bipolar disorders in adults. In addition, the scope of this current manuscript outlines recommendations on the use of treatment guidelines, levels of evidence available to support these recommendations, general considerations for the treatment of bipolar disorders, the so-called pseudoresistance and adherence to treatment, general considerations on psychological therapies, as well as long term treatment of bipolar disorders.

Este documento corresponde a la segunda parte del Tercer Consenso Argentino sobre el manejo de los trastornos bipolares, enfocada en sintetizar la evidencia actualizada sobre los abordajes terapéuticos de esta patología en los pacientes adultos. Siguiendo la metodología descripta en la primera parte del Consenso, el panel de expertos realizó una exhaustiva revisión de la bibliografía y, como consecuencia de un posterior debate sobre la información disponible, se generó esta sección A del segundo documento que abarca el tratamiento integral de las personas adultas que padecen este trastorno. Durante la etapa de debate y discusión de estas guías, se decidió incorporar algunos puntos que estimamos serán de gran utilidad para el equipo interdisciplinario encargado del manejo de pacientes con trastornos bipolares.  En tal sentido, en la sección A de la segunda parte de este documento, se podrán encontrar las recomendaciones generales para el uso de las guías de tratamiento, los niveles de evidencia disponibles para sustentar las recomendaciones, las consideraciones generales del tratamiento de los trastornos bipolares, el fenómeno de pseudorresistencia y adherencia al tratamiento, las consideraciones generales sobre el abordaje psicológico, así como el tratamiento a largo plazo de los trastornos bipolares.

Latin American consensus recommendations for the management and treatment of patients with treatment-resistant depression (TRD).

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD, and available treatment pathways for the management of TRD vary across the Latin American region, highlighting the need for a uniform definition and treatment principles to optimize the management of TRD in Latin America. METHODS: Following a thematic literature review and pre-meeting survey, a Latin America expert panel comprising 14 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA appropriateness method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management. RESULTS: The expert panel agreed that 'treatment-resistant depression' (TRD) is defined as 'failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode'. A stepwise treatment approach should be employed for the management of TRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Nonpharmacological treatments, such as electroconvulsive therapy, are also appropriate options for patients with TRD. CONCLUSION: These consensus recommendations on the operational definition of TRD and approved treatments for its management can be adapted to local contexts in the Latin American countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with TRD.

Third Argentine Consensus statement on management Bipolar Disorders. Section1: introduction and general concepts / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Primera Parte: introducción, método de trabajo y generalidades.

The Third Argentine Consensus on the management of bipolar disorders (TB) is an initiative of the Argentine Association of Biological Psychiatry (AAPB). As a reference document, this consensus pursues two main objectives: on the one hand, to summarize and systematize the best available evidence on the comprehensive management of this pathology; on the other, to provide a useful, up-to-date instrument for psychiatrists, multidisciplinary teams dedicated to mental health, and government agencies. During a period of approximately six months of work -that is, from May to October 2022- a committee of experts made up of 18 professionals and representatives of the three most important Psychiatry and Mental Health associations in Argentina (that is, the AAPB, the Argentine Association of Psychiatrists, AAP, and the Association of Argentine Psychiatrists, APSA) have focused on updating the information regarding TB. Finally, this document was prepared as a result of an exhaustive review of the bibliography published to date, which was strategically divided into three parts: the first deals with the generalities of TB; the second deals with the comprehensive treatment of the pathology; finally, the third analyzes TB in the context of special situations.

El Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares (TB) es una iniciativa de la Asociación Argentina de Psiquiatría Biológica (AAPB). Como documento de referencia, este consenso persigue dos objetivos principales: por un lado, resumir y sistematizar la mejor evidencia disponible sobre el manejo integral de esta patología; por el otro, proporcionar un instrumento útil y actualizado a psiquiatras, a equipos multidisciplinarios abocados a la salud mental y a organismos gubernamentales. Durante un período de aproximadamente seis meses de trabajo -desde mayo a octubre de 2022- un comité de expertos integrado por 18 profesionales y por representantes de las tres asociaciones de Psiquiatría y Salud Mental más importantes de la Argentina: la AAPB, la Asociación Argentina de Psiquiatras, (AAP) y la Asociación de Psiquiatras Argentinos (APSA), se abocaron a actualizar la información respecto de los TB. Finalmente, y como resultado de una exhaustiva revisión de la bibliográfica publicada hasta la actualidad, se confeccionó este documento que fue dividido estratégicamente en tres partes: la primera versa acerca de las generalidades del TB; la segunda aborda el  tratamiento integral de la patología; y, por último, la tercera analiza los TB en el contexto de situaciones especiales.

"Apples and pears are similar, but still different things." Bipolar disorder and schizophrenia- discrete disorders or just dimensions ?

Starting with the dichotomous view of Kraepelin, schizophrenia and bipolar disorder have traditionally been considered as separate entities. More recent, this taxonomic view of illnesses has been challenged and a continuum psychosis has been postulated based on genetic and neurobiological findings suggestive of a large overlap between disorders. In this paper we will review clinical and experimental data from genetics, morphology, phenomenology and illness progression demonstrating what makes schizophrenia and bipolar disorder different conditions, challenging the idea of the obsolescence of the categorical approach. However, perhaps it is also time to move beyond DSM and search for more refined clinical descriptions that could uncover clinical invariants matching better with molecular data. In the future, computational psychiatry employing artificial intelligence and machine learning might provide us a tool to overcome the gap between clinical descriptions (phenomenology) and neurobiology.

Reducing the stigma of mental health disorders with a focus on low- and middle-income countries.

Mental health disorders are a burgeoning global public health challenge, and disproportionately affect the poor. Low- and middle-income countries (LMICs) bear 80 % of the mental health disease burden. Stigma associated with mental health results in delayed help seeking, reduced access to health services, suboptimal treatment, poor outcomes and an increased risk of individuals' human rights violations. Moreover, widespread co-occurrence of physical comorbidities such as noncommunicable diseases with mental health disorders makes the treatment of both conditions challenging and worsens prognosis. This paper explores various aspects of stigma towards mental health with a focus on LMICs and assesses measures to increase help-seeking and access to and uptake of mental health services. Stigma impacts persons living with mental illness, their families and caregivers and healthcare professionals (mental health professionals, non-psychiatric specialists and general practitioners) imparting mental health care. Cultural, socio-economic and religious factors determine various aspects of mental health in LMICs, ranging from perceptions of health and illness, health seeking behavior, attitudes of the individuals and health practitioners and mental health systems. Addressing stigma requires comprehensive and inclusive mental health policies and legislations; sustainable and culturally-adapted awareness programs; capacity building of mental health workforce through task-shifting and interprofessional approaches; and improved access to mental health services by integration with primary healthcare and utilizing existing pathways of care. Future strategies targeting stigma reduction must consider the enormous physical comorbidity burden associated with mental health, prioritize workplace interventions and importantly, address the deterioration of population mental health from the COVID-19 pandemic.

Cognitive-behavioural interventions for attention deficit hyperactivity disorder (ADHD) in adults.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is a developmental condition characterised by symptoms of inattention, hyperactivity and impulsivity, along with deficits in executive function, emotional regulation and motivation. The persistence of ADHD in adulthood is a serious clinical problem.ADHD significantly affects social interactions, study and employment performance.Previous studies suggest that cognitive-behavioural therapy (CBT) could be effective in treating adults with ADHD, especially when combined with pharmacological treatment. CBT aims to change the thoughts and behaviours that reinforce harmful effects of the disorder by teaching people techniques to control the core symptoms. CBT also aims to help people cope with emotions, such as anxiety and depression, and to improve self-esteem. OBJECTIVES: To assess the effects of cognitive-behavioural-based therapy for ADHD in adults. SEARCH METHODS: In June 2017, we searched CENTRAL, MEDLINE, Embase, seven other databases and three trials registries. We also checked reference lists, handsearched congress abstracts, and contacted experts and researchers in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating any form of CBT for adults with ADHD, either as a monotherapy or in conjunction with another treatment, versus one of the following: unspecific control conditions (comprising supportive psychotherapies, no treatment or waiting list) or other specific interventions. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures suggested by Cochrane. MAIN RESULTS: We included 14 RCTs (700 participants), 13 of which were conducted in the northern hemisphere and 1 in Australia.Primary outcomes: ADHD symptomsCBT versus unspecific control conditions (supportive psychotherapies, waiting list or no treatment)- CBT versus supportive psychotherapies: CBT was more effective than supportive therapy for improving clinician-reported ADHD symptoms (1 study, 81 participants; low-quality evidence) but not for self-reported ADHD symptoms (SMD -0.16, 95% CI -0.52 to 0.19; 2 studies, 122 participants; low-quality evidence; small effect size).- CBT versus waiting list: CBT led to a larger benefit in clinician-reported ADHD symptoms (SMD -1.22, 95% CI -2.03 to -0.41; 2 studies, 126 participants; very low-quality evidence; large effect size). We also found significant differences in favour of CBT for self-reported ADHD symptoms (SMD -0.84, 95% CI -1.18 to -0.50; 5 studies, 251 participants; moderate-quality evidence; large effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: CBT with pharmacotherapy was more effective than pharmacotherapy alone for clinician-reported core symptoms (SMD -0.80, 95% CI -1.31 to -0.30; 2 studies, 65 participants; very low-quality evidence; large effect size), self-reported core symptoms (MD -7.42 points, 95% CI -11.63 points to -3.22 points; 2 studies, 66 participants low-quality evidence) and self-reported inattention (1 study, 35 participants).CBT versus other interventions that included therapeutic ingredients specifically targeted to ADHD: we found a significant difference in favour of CBT for clinician-reported ADHD symptoms (SMD -0.58, 95% CI -0.98 to -0.17; 2 studies, 97 participants; low-quality evidence; moderate effect size) and for self-reported ADHD symptom severity (SMD -0.44, 95% CI -0.88 to -0.01; 4 studies, 156 participants; low-quality evidence; small effect size).Secondary outcomesCBT versus unspecific control conditions: we found differences in favour of CBT compared with waiting-list control for self-reported depression (SMD -0.36, 95% CI -0.60 to -0.11; 5 studies, 258 participants; small effect size) and for self-reported anxiety (SMD -0.45, 95% CI -0.71 to -0.19; 4 studies, 239 participants; small effect size). We also observed differences in favour of CBT for self-reported state anger (1 study, 43 participants) and self-reported self-esteem (1 study 43 participants) compared to waiting list. We found no differences between CBT and supportive therapy (1 study, 81 participants) for self-rated depression, clinician-rated anxiety or self-rated self-esteem. Additionally, there were no differences between CBT and the waiting list for self-reported trait anger (1 study, 43 participants) or self-reported quality of life (SMD 0.21, 95% CI -0.29 to 0.71; 2 studies, 64 participants; small effect size).CBT plus pharmacotherapy versus pharmacotherapy alone: we found differences in favour of CBT plus pharmacotherapy for the Clinical Global Impression score (MD -0.75 points, 95% CI -1.21 points to -0.30 points; 2 studies, 65 participants), self-reported depression (MD -6.09 points, 95% CI -9.55 points to -2.63 points; 2 studies, 66 participants) and self-reported anxiety (SMD -0.58, 95% CI -1.08 to -0.08; 2 studies, 66 participants; moderate effect size). We also observed differences favouring CBT plus pharmacotherapy (1 study, 31 participants) for clinician-reported depression and clinician-reported anxiety.CBT versus other specific interventions: we found no differences for any of the secondary outcomes, such as self-reported depression and anxiety, and findings on self-reported quality of life varied across different studies. AUTHORS' CONCLUSIONS: There is low-quality evidence that cognitive-behavioural-based treatments may be beneficial for treating adults with ADHD in the short term. Reductions in core symptoms of ADHD were fairly consistent across the different comparisons: in CBT plus pharmacotherapy versus pharmacotherapy alone and in CBT versus waiting list. There is low-quality evidence that CBT may also improve common secondary disturbances in adults with ADHD, such as depression and anxiety. However, the paucity of long-term follow-up data, the heterogeneous nature of the measured outcomes, and the limited geographical location (northern hemisphere and Australia) limit the generalisability of the results. None of the included studies reported severe adverse events, but five participants receiving different modalities of CBT described some type of adverse event, such as distress and anxiety.

Depressive symptoms and the role of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD): A comparison with bipolar disorder.

OBJECTIVES: To investigate the characteristics of depressive symptoms and the influence of affective temperament in adults with attention-deficit/hyperactivity disorder (ADHD), in comparison with bipolar disorder (BD) patients and healthy controls (HCs). METHOD: Sixty patients with ADHD, 50 patients with BD, and 30 HCs were assessed with instruments for measuring depressive symptoms (Beck Depression Inventory-II), and affective temperaments (Temperament Scale of Memphis, Pisa and San Diego, self-administered version; TEMPS-A). In addition, participants were evaluated with scales for measuring ADHD symptoms, impulsiveness, anxiety, executive dysfunction, and quality of life. RESULTS: ADHD patients showed levels of depressive symptoms similar to BD patients and higher than HCs. Only neurovegetative symptoms of depression differentiated ADHD and BD groups (BD > ADHD). Depressive symptoms in ADHD patients correlated positively with core ADHD, impulsivity, anxiety, and dysexecutive symptoms and negatively with quality of life. Thirty-eight percent of patients with ADHD scored above the cutoff for at least one affective temperament. Cyclothymic was the more common affective temperament (25%). ADHD patients with affective temperamental traits were more depressed and impulsive than patients without those traits and showed a symptomatic profile analogous to BD patients. LIMITATIONS: The small size of resultant samples when ADHD group was stratified by the presence of affective temperament. In addition, results may not generalize to less severe ADHD patients from the community. CONCLUSIONS: Concomitant depressive symptoms constitute a common occurrence in adults with ADHD that carries significant psychopathological and functional consequences. The concept of affective temperaments may be an interesting link for explaining depressive symptomatology and emotional impulsivity in a subgroup of patients with ADHD, beyond the classic idea of comorbidity.

Psychiatrists' approach to vascular risk assessment in Latin America.

AIM: To explore the way in which Latin American psychiatrists approach the screening of vascular risk factors in patients receiving antipsychotic medication. METHODS: This was a descriptive, cross sectional study that surveyed Latin-American physicians to evaluate differences between groups divided in three main sections. The first section included demographic and professional data. The second section asked about the available medical resources: weighing scales, sphygmomanometer and measuring tape. Finally, the third section aimed at looking into the attitudes towards cardiovascular prevention. The latter was also divided into two subsections. In the first one, the questions were about weight, blood pressure and waist perimeter. In the second subsection the questions asked about the proportion of patients: (1) that suffered from overweight and/or obesity; (2) whose lipids and glycemia were controlled by the physician; (3) that were questioned by, and received information from the physician about smoking; and (4) that received recommendations from the physician to engage in regular physical activity. The participants were physicians, users of the medical website Intramed. The visitors were recruited by a banner that invited them to voluntarily access an online self-reported structured questionnaire with multiple options. RESULTS: We surveyed 1185 general physicians and 792 psychiatrists. Regarding basic medical resources, a significantly higher proportion of general physicians claimed to have weighing scales (χ(2) = 404.9; P < 0.001), sphygmomanometers (χ(2) = 419.3; P < 0.001), and measuring tapes (χ(2) = 336.5; P < 0.001). While general physicians measured overweight and metabolic indexes in the general population in a higher proportion than in patients treated with antipsychotics (Z = -11.91; P < 0.001), psychiatrists claimed to measure them in patients medicated with antipsychotics in a higher proportion than in the general population (Z = -3.26; P < 0.001). Also general physicians tended to evaluate smoking habits in the general population more than psychiatrists (Z = -7.02; P < 0.001), but psychiatrists evaluated smoking habits in patients medicated with antipsychotics more than general physicians did (Z = -2.25; P = 0.024). General physicians showed a significantly higher tendency to control blood pressure (χ(2) = 334.987; P < 0.001), weight (χ(2) = 435.636; P < 0.001) and waist perimeter (χ(2) = 96.52; P < 0.001) themselves and they did so in all patients. General physicians suggested physical activity to all patients more frequently (Z = -2.23; P = 0.026), but psychiatrists recommended physical activity to patients medicated with antipsychotics more frequently (Z = -7.53; P < 0.001). CONCLUSION: Psychiatrists usually check vascular risk factors in their patients, especially in those taking antipsychotics. General practitioners check them routinely without paying special attention to this population.

Personality changes in dementia: are they disease specific and universal?

Previous studies about personality changes in dementia suggest that they may be due to the disruption of the biological basis of personality traits, and hence, that they are disease specific and universal. However, evidence about its specificity is still limited and scarce regarding culturally diverse populations. Accordingly, our aim was to compare personality changes in Argentinean patients with Alzheimer disease, behavioral variant of frontotemporal dementia, and primary progressive aphasia. The closest living relatives of patients diagnosed with Alzheimer disease (n=19), behavioral variant of frontotemporal dementia (n=16), and primary progressive aphasia (n=15) were asked to complete 2 versions of the personality inventory NEO Personality Inventory-Revised, one for assessing patients' premorbid personality traits, and the other for assessing current traits. All groups showed changes in several domains and facets of the NEO Personality Inventory-Revised. Globally, the observed pattern of changes was fairly consistent with previous studies based on the same model of personality. Nevertheless, our results regarding disease-specificity were less conclusive. Even if there were some indicators of specific differences between groups, most traits varied similarly across the 3 groups, revealing a pattern of generalized changes in personality expression after illness onset. More studies are needed that help to distinguish real personality changes from other affective or cognitive symptoms that accompany dementia, as well as further data from culturally diverse populations.

Dysfunctional cognitions and their emotional, behavioral, and functional correlates in adults with attention deficit hyperactivity disorder (ADHD): is the cognitive-behavioral model valid?

OBJECTIVE: To investigate the presence of dysfunctional cognitions in adults with ADHD and to determine whether these cognitions are associated with emotional symptoms, maladaptive coping, and functional impairment, as predicted by the cognitive-behavioral model. METHOD: A total of 35 adult participants with ADHD, 20 nonclinical controls, and 20 non-ADHD clinical controls were assessed with measures of ADHD symptoms, dysfunctional cognitions, depression and anxiety symptoms, coping strategies, and quality of life. RESULTS: ADHD group showed elevated scores of dysfunctional cognitions relative to nonclinical control group and comparable with clinical control group. Dysfunctional cognitions were strongly associated with emotional symptoms. ADHD group also showed elevated scores in maladaptive coping strategies of the escape-avoidance type. Life impairment was satisfactorily predicted in data analysis when ADHD symptoms, dysfunctional cognitions, and emotional symptoms were fitted into a regression model. CONCLUSION: Cognitive-behavioral therapy model appears to be a valid complementary model for understanding emotional and life impairment in adults with ADHD.

[Psychometric properties of the Barratt Impulsiveness Scale in a sample of the city of Buenos Aires]. / Propiedades psicométricas de la Escala de Impulsividad de Barratt en una muestra de Buenos Aires.

The Barratt Impulsiveness Scale was designed to assess the impulsivity construct in three dimensions: attentional, motor and unplanned. The scale has been applied to patients with different diagnoses in which the impulsivity symptoms are characteristic. In Argentina there aren't studies that evaluate the psychometrics properties of the scale in clinical population. The objective of the research was to evaluate the psychometrics properties in a sample of the city of Buenos Aires. 150 adult subjects were selected: 67 didn't have relevant psychiatric diagnoses, 56 met criteria for bipolar disorder and 27 had Attention Deficit Disorder. The internal consistency, the construct validity, discriminative validity and the factorial structure were assessed. The Cronbach alpha was 0.84 for the total scale. Also the instrument has demonstrated acceptable indicators of construct and discriminative validity. Significant differences were found when the results of the present study and the original factorial structure were compared. The results support the usefulness of the scale in the psychiatric, scientific and clinical context to evaluate the impulsivity construct. The total score of the scale obtained the strongest indicators of reliability and validity.

[Medical comorbidity in psychiatric disorders]. / Comorbilidades médicas en los trastornos psiquiátricos.

Understand that in addition to the problems inherent to mental conditions the people suffer associated medical conditions that further complicate their condition and endanger its vitality is paramount. Of course this requires fundamental premise construct understanding of mental health within the medical model of care. As mentioned above we make the following literature review focusing on understanding the interaction between depression and cardiovascular disease mainly and reviewing other comorbidities and their impact on our patients. We show also that several factors contribute to poor physical health of people with psychiatric disorders including different individual choices in lifestyle determined by its pathologies and on the other hand a marked disparity in access, utilization and health care provision.

[Clinical concepts associated with lithium underutilization in the treatment of bipolar disorder]. / Conceptos clínicos asociados a la subestimación del litio en el tratamiento del Trastorno Bipolar.

OBJECTIVES: Bipolar Disorders are among the ten leading causes of morbity and lithium is considered first-line treatment and the most cost-effective. Nevertheless, its use takes a back seat to other treatment options less effective, safe and more expensive; and the reasons for this remains unclear. The present study investigates clinical concepts related to its underutilization. METHOD: An anonymous questionnaire concerning different aspects of lithium clinical use (compared efficacy, adverse effects, practical aspects regarding its use, use in special populations) was administered during the XXV Congress of the Argentinean Psychiatrist Association. RESULTS: 164 questionnaires were analyzed. Less than one-third of the sample referred lithium as their most frequent treatment option, although almost 60% qualified it as effective. Almost two-thirds considered its utilization as more complex and ill-ascribed adverse effects to it. One third referred not to use it in youth and senior populations. CONCLUSIONS: Contrary to current recommendations, lithium is under utilized. This is the first report on the possible causes leading to such phenomena, which can be related to ill concepts regarding its safety, clinical use and adverse effects; although not to its effectiveness.

Physical illness in patients with severe mental disorders. II. Barriers to care, monitoring and treatment guidelines, plus recommendations at the system and individual level.

Physical disorders are, compared to the general population, more prevalent in people with severe mental illness (SMI). Although this excess morbidity and mortality is largely due to modifiable lifestyle risk factors, the screening and assessment of physical health aspects remains poor, even in developed countries. Moreover, specific patient, provider, treatment and system factors act as barriers to the recognition and to the management of physical diseases in people with SMI. Psychiatrists can play a pivotal role in the improvement of the physical health of these patients by expanding their task from clinical psychiatric care to the monitoring and treatment of crucial physical parameters. At a system level, actions are not easy to realize, especially for developing countries. However, at an individual level, even simple and very basic monitoring and treatment actions, undertaken by the treating clinician, can already improve the problem of suboptimal medical care in this population. Adhering to monitoring and treatment guidelines will result in a substantial enhancement of physical health outcomes. Furthermore, psychiatrists can help educate and motivate people with SMI to address their suboptimal lifestyle, including smoking, unhealthy diet and lack of exercise. The adoption of the recommendations presented in this paper across health care systems throughout the world will contribute to a significant improvement in the medical and related psychiatric health outcomes of patients with SMI.

Physical illness in patients with severe mental disorders. I. Prevalence, impact of medications and disparities in health care.

The lifespan of people with severe mental illness (SMI) is shorter compared to the general population. This excess mortality is mainly due to physical illness. We report prevalence rates of different physical illnesses as well as important individual lifestyle choices, side effects of psychotropic treatment and disparities in health care access, utilization and provision that contribute to these poor physical health outcomes. We searched MEDLINE (1966 - August 2010) combining the MeSH terms of schizophrenia, bipolar disorder and major depressive disorder with the different MeSH terms of general physical disease categories to select pertinent reviews and additional relevant studies through cross-referencing to identify prevalence figures and factors contributing to the excess morbidity and mortality rates. Nutritional and metabolic diseases, cardiovascular diseases, viral diseases, respiratory tract diseases, musculoskeletal diseases, sexual dysfunction, pregnancy complications, stomatognathic diseases, and possibly obesity-related cancers are, compared to the general population, more prevalent among people with SMI. It seems that lifestyle as well as treatment specific factors account for much of the increased risk for most of these physical diseases. Moreover, there is sufficient evidence that people with SMI are less likely to receive standard levels of care for most of these diseases. Lifestyle factors, relatively easy to measure, are barely considered for screening; baseline testing of numerous important physical parameters is insufficiently performed. Besides modifiable lifestyle factors and side effects of psychotropic medications, access to and quality of health care remains to be improved for individuals with SMI.

Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders.

OBJECTIVE: To assess the sensitivity and specificity of two self-report instruments for detection of bipolarity in a sample of Argentinean patients. METHOD: Spanish versions of the MDQ and the BSDS were administered over four months at 11 sites in Argentina. Diagnoses were made using DSM-IV criteria and the MINI. The study sample consisted of patients diagnosed with Bipolar Disorder (BD) Types I, II, or NOS. BDNOS diagnoses were made using extended guidelines for bipolar spectrum symptoms. Unipolar patients were used as a control group. Of 493 patients screened, 354 completed evaluation by MDQ and MINI, and 363 by BSDS and MINI. RESULTS: Specificity of MDQ was 0.97 and BSDS was 0.81. MDQ sensitivity was 0.70 for bipolar type I (BD-I), 0.52 for bipolar II (BD-II) and 0.31 for bipolar not otherwise specified (BDNOS). BSDS sensitivities were 0.75, 0.70 and 0.51 respectively. LIMITATIONS: This study was performed in specialized outpatient settings and thus its results are not necessarily representative for other clinical settings. There was not a systematic evaluation of comorbid psychiatric disease or test-retest reliability. CONCLUSION: The local versions of the MDQ and the BSDS showed a sensitivity and specificity comparable to previous research. Our results indicate that in this sample, MDQ was more specific for BD and BSDS was more sensitive to detect BD-II and NOS. Since BD-I is more readily recognized than bipolar spectrum disorders, enhanced sensitivity of BSDS for soft bipolarity may be an advantage.

[2nd Argentine consensus on the treatment of bipolar disorders 2010]. / II Consenso argentino sobre el tratamiento de los trastornos bipolares 2010.

The consensus guidelines of Argentine experts in the treatment of bipolar disorders are the result of three days of work of the 9 main local experts under the organization of the Argentine Association of Mood Disorders (ASATHU). This work is an update of the guidelines published on this journal in 2006. It was adopted a mixed criterion for its preparation: all the recent data of the evidence medicine based published until now were discussed and were balanced with the knowledge acquired from clinical experience of the local experts on the bipolar field. It presents general recommendations and suggested therapeutic sequences for maintenance, manic/hypomanic or mixed episode and depressive episode treatments. Bipolar disorders have been divided according to the international classifications in type I and II; with or without rapid cycling. This work also includes a series of recommendations for early and differential diagnosis of bipolar disorders.