Brazilian Psychiatric Association guidelines for the treatment of generalized anxiety disorder (GAD). Pharmacological and Psychotherapy approach. Perspectives.

OBJECTIVE: To combine elements of a systematic review and critical review to produce best evidence synthesis for the treatament of GAD. METHOD: There was included systematic reviews, metanalysis, and randomized controlled trials. Descriptor used was "generalized anxiety disorder", resulting in 4860 articles and 7 other studies, of which 59 were selected. RESULTS: Antidepressants and benzodiazepines are indicated, as well as pregabalin. From, atypical antipsychotics quetiapine has been studied. Cognitive behavior therapy (third wave of behavioral and cognitive therapies) as well as individual CBT proven to be effective. CONCLUSION: There is extensive literature on many effective treatments for GAD. The present work summarizes the therapeutic possibilities, emphasizing those available in the Brazil. Further studies are still needed to compare other available medications, to assess psychotherapies in more depth, new treatments and specially to assess the ideal time for maintaining therapy.

A cross-sectional study to compare levels of psychiatric morbidity between young people and adults exposed to violence in a large urban center.

BACKGROUND: Teenagers and young adults are more exposed to violence and traumatic events than adults, and these factors can be associated with mental disorders. This paper aims at investigating whether young people are more exposed to violence and traumatic events and to compare pattern of mental disorders with adults. METHODS: Cross-sectional study using the Composite International Diagnostic Interview, conducted between 2007 and 2008 with a randomly selected sample of 15 to 75 year-old residents of São Paulo, Brazil. RESULTS: Two thousand five hundred thirty-six participants were divided into two groups: 1096 (43.2 %) young people (15 to 24 years), and 1440 (56.8 %) adults (25 to 75 years). 12-month exposure to traumatic events was higher among young people (32.1 % vs. 20.6 %; p < 0.001). Assaultive violence was reported by 13.4 % of young people and 8.6 % of adults (p = 0.012); 20.1 % of young people and 13 % of adults reported suffering other injury or shocking events (p < 0.001); sudden death/life threatening illness of a close person was declared by 6.1 % of young people and 3.2 % of adults (p = 0.017). Prevalence of alcohol related disorders was higher among young people (5.4 % vs. 2.5 %; P = 0.032); depressive disorders were more prevalent among adults (9.0 % vs. 4.7 %; P = 0.004). Alcohol related disorders were associated to assaultive violence among young people (OR = 3.4; 95 % CI = 1.36 to 8.52; p = 0.004) and adults (OR = 2.38; 95 % CI = 1.23 to 4.61; p = 0.002). Phobic/anxiety disorders were associated to other injury or shocking events among young people (OR = 1.28; 95 % CI = 0.67 to 2.44; p = 0.025). Major depressive disorder was associated to assaultive violence among young people (OR = 2.27; 95 % CI = 1.09 to 4.74; p = 0.004) and adults (OR = 1.28; 95 % CI = 0.85 to 1.93; p = 0.009). CONCLUSION: Exposure to violence and traumatic events was higher among young people. Alcohol related disorders, depression and phobic/anxiety disorders were significantly higher among young people exposed to traumatic events. Despite the study design, high exposure to violence and traumatic events in this age group can be considered important factors in triggering mental disorders in this vulnerable age period.

The Concept of Peritraumatic Dissociation: A Qualitative Approach.

Peritraumatic dissociation has been considered an important feature for the development of post-traumatic stress disorders, but this concept remains widely unclear. To explore the peritraumatic experience, we interviewed eight victims of urban violence shortly after their traumatic events. The data collected were compared and analyzed according to the systematic set of procedures of Grounded Theory (GT). The alterations reported by participants were coded and categorized according to their perceptions of their inner and outer world, and the impressions of others involved, including the examiner's observations. The theoretical perspective for interpreting this study has parallels with Jaspers' psychopathology. Peritraumatic dissociation was conceived as a failure of synthesis among emerging stimuli from the internal and the external world, including the time-space flow structure, even when cognitive-perceptual tools remain intact. This synthesis qualifies the totality of the perceptual experience as coherent and meaningful to conscience, enabling possibilities for being/existing.

Health-related quality of life in posttraumatic stress disorder: 4 years follow-up study of individuals exposed to urban violence.

Evidence suggests that Posttraumatic Stress Disorder (PTSD) is associated with substantially reduced Health-related quality of life (HRQoL). This study aimed to explore the impact of PTSD symptoms in HRQoL and its predictors in individuals exposed to urban violence. We follow-up a cohort of 267 individuals exposed to urban violence, derived from an epidemiological survey and clinical cases from an outpatient program of victims of violence, with and without PTSD, by assessing symptoms and other measures at two intervals, approximately 4 years apart. PTSD symptom severity was associated with poorer quality of life at baseline and at follow-up. Higher levels of depression and anxiety, new trauma experiences, more traumas in childhood and more PTSD arousal symptoms were all predictors of lower HRQoL over time. Results strongly suggest the need to assess HRQoL in addition to symptoms in order to assess the true severity of PTSD. These results have implications for the functional recovery in the treatment of PTSD.

Structural validity of the tonic immobility scale in a population exposed to trauma: evidence from two large Brazilian samples.

BACKGROUND: Tonic Immobility is a temporary state of motor inhibition in situations involving extreme fear. The first scale developed for its assessment was the 10-item Tonic Immobility Scale (TIS). However, there are still few studies on its structural (dimensional) validity. The objective of this study was to reassess the factor structure of the TIS applied to representative samples exposed to general trauma of two Brazilian mega-cities. METHODS: The sample comprised 3,223 participants reporting at least one traumatic experience. In São Paulo (n = 2,148), a Confirmatory Factor Analysis (CFA) first tested the originally proposed two-dimensional structure. This was followed by sequential Exploratory Structural Equation Models to identify the best fitting model, and subsequently tested in Rio de Janeiro (n = 1,075) via CFA. Alternative reduced versions were further explored using the aggregate sample. Model-based Item Response Theory (IRT) location parameters were also investigated. RESULTS: An absence of factor-based convergent and discriminant validity rejected the original proposition. However, the one-dimensional structure still held several residual correlations. Further exploration indicated the sustainability of reduced versions with seven (alternative A) and six (alternative B) items. Both presented excellent fit and no relevant residual item correlation. According to the IRT location parameters, items in alternative B covered a wider range of the latent trait. The Loevinger's H scalability coefficients underscored this pattern. CONCLUSIONS: The original model did not hold. A one-factor solution was the most tenable in both large samples, but with significant item residual correlations, indicating that content redundancies persisted. Further reduced and simplified versions of the TIS proved promising. Although studies are yet to be carried out in other settings, it is the authors' impression that the restricted versions of the TIS are already apt for use in epidemiologic studies since the pros tend to outweigh the cons (as outlined in the Discussion section).

The impact of epidemic violence on the prevalence of psychiatric disorders in Sao Paulo and Rio de Janeiro, Brazil.

BACKGROUND: Violence and other traumatic events, as well as psychiatric disorders are frequent in developing countries, but there are few population studies to show the actual impact of traumatic events in the psychiatric morbidity in low and middle-income countries (LMIC). AIMS: To study the relationship between traumatic events and prevalence of mental disorders in São Paulo and Rio de Janeiro, Brazil. METHODS: Cross-sectional survey carried out in 2007-2008 with a probabilistic representative sample of 15- to 75-year-old residents in Sao Paulo and Rio de Janeiro, Brazil, using the Composite International Diagnostic Interview. RESULTS: The sample comprised 3744 interviews. Nearly 90% of participants faced lifetime traumatic events. Lifetime prevalence of any disorders was 44% in Sao Paulo and 42.1% in Rio de Janeiro. One-year estimates were 32.5% and 31.2%. One-year prevalence of traumatic events was higher in Rio de Janeiro than Sao Paulo (35.1 vs. 21.7; p<0.001). Participants from Rio de Janeiro were less likely to have alcohol dependence (OR = 0.55; p = 0.027), depression (OR = 0.6; p = 0.006) generalized anxiety (OR = 0.59; p = 0.021) and post-traumatic stress disorder (OR = 0.62; p = 0.027). Traumatic events correlated with all diagnoses--e.g. assaultive violence with alcohol dependence (OR = 5.7; p<0.001) and with depression (OR = 1.7; p = 0.001). CONCLUSION: Our findings show that psychiatric disorders and traumatic events, especially violence, are extremely common in Sao Paulo and Rio de Janeiro, supporting the idea that neuropsychiatric disorders and external causes have become a major public health priority, as they are amongst the leading causes of burden of disease in low and middle-income countries. The comparison between the two cities regarding patterns of violence and psychiatric morbidity suggests that environmental factors may buffer the negative impacts of traumatic events. Identifying such factors might guide the implementation of interventions to improve mental health and quality of life in LMIC urban centers.

A multicenter study of bipolar disorder among emergency department patients in Latin-American countries.

OBJECTIVE: This multicenter study estimated the prevalence of bipolar disorder (BPD) among emergency department (ED) patients in Latin America. METHODS: To identify patients with BPD, a combination of DSM IV-criteria interview and the Mood Disorder Questionnaire (MDQ) was used. Data from 1,505 patients from hospitals in Argentina, Brazil, Chile, Colombia, and Mexico was analyzed. RESULTS: The prevalence ofBPD in this sample was 5.2% (95% CI = 4.5% to 6.9%). The mean age was 37 years (response rate of 83.0%). Compared to non-BPD patients, BPD patients were more likely to report asthma (16.7% vs. 9%), thyroid problems (12.8% vs. 5.8%), seizures (23.1% vs. 3.0%), obesity (39.7% vs. 26.9%), alcohol abuse (30.8% vs. 10.0%), attention deficit hyperactivity disorders (50.0% vs. 12.0%), depression (81.6% vs. 45.7%), obsessive compulsive disorder (20.1% vs. 3.0%), panic disorders (23.1% vs. 12.3%), phobic disorders (11.2% vs. 3.1%), and any anxiety disorder (82.1 % vs. 41.8%; all p < or = 0.05). Suicidal plans and attempts were also significant higher in the bipolar group (11.5% vs. 2.8% and 10.3% vs. 1.8% respectively). Multivariate analysis identified ADHD, depression, alcohol abuse, anxiety disorder, and last month suicide plans and attempts to be independently associated with BPD. CONCLUSION: Our study supports that BPD is prevalent in ED in Latin-American countries and that comorbidity is the rule, not the exception. Patients presenting at ED with irritability, anxiety, pressure speech, euphoria, with suicidal tendencies, involved in risky behaviors, alcohol abuse, dependence or those with history of mental health hospitalization in the past 12 months must be assessed for comorbid BPD.

Evaluation of physical activity habits in patients with posttraumatic stress disorder.

OBJECTIVE: In this study, we present data from a survey that aimed to assess the physical activity habits of adult Brazilian patients with Posttraumatic Stress Disorder. METHOD: Fifty male and female patients with Posttraumatic Stress Disorder participated in this study. The mean age at onset was 37+/-12 years, and the mean time between diagnosis and follow-up was 3.6+/-4.2 years. RESULTS: Substantial changes in physical activity habits were observed following the onset of PTSD. While more than half of the patients participated in physical activities prior to Posttraumatic Stress Disorder onset, there was a significant reduction in their participation afterwards. The justifications for stopping physical activities or sport participation were lack of time and lack of motivation. DISCUSSION: Several studies have shown that physical exercise decreases reverts symptoms of psychiatric disorders such as depression, anxiety and social isolation. We could therefore hypothesize that patients with Posttraumatic Stress Disorder who exercise should experience the same benefits. CONCLUSION: Our findings demonstrated that patients with Posttraumatic Stress Disorder have low levels of participation in sports or physical activities.

A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders.

OBJECTIVE: Interpersonal psychotherapy (IPT) is a time-limited psychotherapy for major depression. The aim of this study is to summarize findings from controlled trials of the efficacy of IPT in the treatment of depressive spectrum disorders (DSD) using a meta-analytic approach. METHODS: Studies of randomized clinical trials of IPT efficacy were located by searching all available data bases from 1974 to 2002. The searches employed the following MeSH categories: Depression/ Depressive Disorder; Interpersonal therapy; Outcome/Adverse Effects/Efficacy; in the identified studies. The efficacy outcomes were: remission; clinical improvement; the difference in depressive symptoms between the two arms of the trial at endpoint, and no recurrence. Drop out rates were used as an index of treatment acceptability. RESULTS: Thirteen studies fulfilled inclusion criteria and four meta-analyses were performed. IPT was superior in efficacy to placebo in nine studies (Weight Mean Difference (WMD) - 3.57 [-5.9, -1.16]). The combination of IPT and medication did not show an adjunctive effect compared to medication alone for acute treatment (RR 0.78 [0.30, 2.04]), for maintenance treatment (RR 1.01 [0.81, 1.25]), or for prophylactic treatment (RR 0.70 [0.30, 1.65]). IPT was significantly better than CBT (WMD -2.16 [-4.16,-0.15]). CONCLUSION: The efficacy of IPT proved to be superior to placebo, similar to medication and did not increase when combined with medication. Overall, IPT was more efficacious than CBT. Current evidence indicates that IPT is an efficacious psychotherapy for DSD and may be superior to some other manualized psychotherapies.