Factores de riesgo para intento de suicidio en personas con trastorno depresivo en atención secundaria / Risk factors for suicide attempts in people with depressive disorders treated in secondary health care

Background: Depression is the most common psychiatric disorder in people with suicidal behavior. The knowledge of its risk factors should help to design preventive strategies. Aim: To describe suicidal behavior and risk factors for attempted suicide in people with major depressive disorders (MDD). Material and Methods: A 12-month follow-up study was conducted in 112 outpatients at three psychiatric care centers of Ñuble, Chile, with baseline and quarterly assessments. Demographic, psychosocial and clinical factors as potential risk factors of suicide attempts, were assessed. A clinical interview with DSM-IV diagnostic criteria checklist, Hamilton Depression Scale and the List of Threatening Experiences and Multidimensional Scale of Perceived Social Support were applied. Results: Sixty seven percent of participants had suicidal ideation and 43.8% had attempted suicide. Suicide risk was significantly higher in participants with a single major depressive episode (odds ratio [OR] = 3.98; 95% confidence intervals [CI] = 1,29-12,32 p = 0.02) and those with previous suicide attempts (OR = 13.15; 95% CI = 3,87-44.7 p < 0.01). Young age, not having a partner, being unemployed, having a severe major depressive episode, having psychotic symptoms, having a personality disorder and being devoid of medical illness increased the risk of suicide attempts, but they did not reach statistical significance. Conclusions: Significant risk factors should be specially considered when designing suicide preventive strategies in patients with MDD.

Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial

Objective: There are few quantitative studies on art therapy for the treatment of depression. The objective of this study was to evaluate if art therapy is beneficial as an adjuvant treatment for depression in the elderly. Methods: A randomized, controlled, single-blind study was carried out in a sample of elderly women with major depressive disorder (MDD) stable on pharmacotherapy. The experimental group (EG) was assigned to 20 weekly art therapy sessions (90 min/session). The control group (CG) was not subjected to any adjuvant intervention. Patients were evaluated at baseline and after 20 weeks, using the Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and cognitive measures. Results: Logistic regression analysis adjusted for age revealed that women in EG (n=31) had significant improvement in GDS (p = 0.007), BDI (p = 0.025), and BAI (p = 0.032) scores as compared with controls (n=25). No difference was found in the cognitive measures. Conclusion: Art therapy as an adjunctive treatment for MDD in the elderly can improve depressive and anxiety symptoms. Clinical trial registration: RBR-2YXY7Z

Predictores de remisión del trastorno depresivo mayor en tratamiento en el nivel secundario de atención / Predictors of remission from major depressive disorder in secondary care

Background The knowledge of predictive factors in depression should help to deal with the disease. Aim To assess potential predictors of remission of major depressive disorders (MDD) in secondary care and to propose a predictive model. Material and Methods A 12 month follow-up study was conducted in a sample of 112 outpatients at three psychiatric care centers of Chile, with baseline and quarterly assessments. Demographic, psychosocial, clinical and treatment factors as potential predictors, were assessed. A clinical interview with the checklist of DSM-IV diagnostic criteria, the Hamilton Depression Scale and the List of Threatening Experiences and Multidimensional Scale of Perceived Social Support were applied. Results The number of stressful events, perceived social support, baseline depression scores, melancholic features, time prior to beginning treatment at the secondary level and psychotherapeutic sessions were included in the model as predictors of remission. Sex, age, number of previous depressive episodes, psychiatric comorbidity and medical comorbidity were not significantly related with remission. Conclusions This model allows to predict depression score at six months with 70% of accuracy and the score at 12 months with 72% of accuracy.

Exercise for depression in older adults: a meta-analysis of randomized controlled trials adjusting for publication bias

Objective: To evaluate the antidepressant effects of exercise in older adults, using randomized controlled trial (RCT) data. Methods: We conducted a meta-analysis of exercise in older adults, addressing limitations of previous works. RCTs of exercise interventions in older people with depression (≥ 60 years) comparing exercise vs. control were eligible. A random-effects meta-analysis calculating the standardized mean difference (SMD) (95% confidence interval [95%CI]), meta-regressions, and trim, fill, and fail-safe number analyses were conducted. Results: Eight RCTs were included, representing 138 participants in exercise arms and 129 controls. Exercise had a large and significant effect on depression (SMD = -0.90 [95%CI -0.29 to -1.51]), with a fail-safe number of 71 studies. Significant effects were found for 1) mixed aerobic and anaerobic interventions, 2) at moderate intensity, 3) that were group-based, 4) that utilized mixed supervised and unsupervised formats, and 5) in people without other clinical comorbidities. Conclusion: Adjusting for publication bias increased the beneficial effects of exercise in three subgroup analysis, suggesting that previous meta-analyses have underestimated the benefits of exercise due to publication bias. We advocate that exercise be considered as a routine component of the management of depression in older adults.

Nivel de conocimientos sobre depresión mayor en médicos de atención primaria en Lambayeque, Perú, 2014 / Knowledge level about major depression in primary care physicians from Lambayeque, Peru, 2014

Objetivos: Evaluar los conocimientos sobre diagnóstico y tratamiento del trastorno depresivo mayor en médicos de atención primaria de la provincia de Chiclayo y determinar su asociación con características sociodemográficas. Material y métodos: Estudio descriptivo transversal con análisis exploratorio de datos. Se realizó un muestreo tipo censal. Se evaluaron a 111 médicos de atención primaria, mediante un instrumento validado, unidimensional, basado en los criterios diagnósticos del DSM-IV para el trastorno depresivo mayor. El análisis univariado y bivariado se realizó con el programa estadístico STATA v. 11.1. Resultados: El nivel de conocimientos fue medio en 18 (16,2%) médicos de atención primaria; y bajo, en 93 (83,8%). Ninguno tuvo un nivel de conocimientos alto. Solo 23 (20,7%) recibieron actualización en salud mental en los últimos 4 años. No se encontró asociación entre el nivel de conocimientos y las variables sociodemográficas. Conclusiones: El nivel de conocimientos en depresión mayor de los médicos de atención primaria de la provincia de Chiclayo fue deficiente. Este hallazgo, sin embargo, no parece estar asociado con las características sociodemográficas de la muestra utilizada.

Objectives: To measure the level of knowledge about the diagnosis and treatment of major depressive disorder among primary care physicians in the province of Chiclayo, and to assess its association with sociodemographic characteristics. Material and Methods: Cross-sectional study with exploratory data analysis. A census-type sampling was performed. One-hundred eleven primary care physicians were evaluated through a unidimensional validated questionnaire, based on DSM-IV diagnostic criteria for major depressive disorder. An univariate and bivariate analysis was performed using STATA statistical software v. 11.1. Results: The knowledge reached a medium level of 18 (16.2%) primary care physicians, and low in 93 (83.8%). None had a high level of knowledge. Only 23 probands (20.7%) had received a mental health update in the last 4 years. No association was found between the level of knowledge and sociodemographic characteristics. Conclusions: The level of knowledge in major depression among primary care physicians from the province of Chiclayo was poor. This finding, however, showed no association with sociodemographic features of the study sample.

In vitro comparison of epidural bacteria filters permeability and screening scanning electron microscopy / Comparação in vitro da permeabilidade de filtros epidurais antibacterianos e triagem por microscopia eletrônica de varredura

BACKGROUND AND OBJECTIVES: Epidural catheter bacteria filters are barriers in the patient-controlled analgesia/anaesthesia for preventing contamination at the epidural insertion site. The efficiency of these filters varies according to pore sizes and materials. METHOD: The bacterial adhesion capability of the two filters was measured in vitro experiment. Adhesion capacities for standard Staphylococcus aureus (ATCC 25923) and Pseudomonas aeruginosa (ATCC 27853) strains of the two different filters (Portex and Rusch) which have the same pore size were examined. Bacterial suspension of 0.5 Mc Farland was placed in the patient-controlled analgesia pump, was filtered at a speed of 5 mL/h. in continuous infusion for 48 h and accumulated in bottle. The two filters were compared with colony counts of bacteria in the filters and bottles. At the same time, the filters and adhered bacteria were monitored by scanning electron microscope. RESULTS: Electron microscopic examination of filters showed that the Portex filter had a granular and the Rusch filter fibrillary structure. Colony counting from the catheter and bottle showed that both of the filters have significant bacterial adhesion capability (p < 0.001). After the bacteria suspension infusion, colony countings showed that the Portex filter was more efficient (p < 0.001). There was not any difference between S. aureus and P. aeruginosa bacteria adhesion. In the SEM monitoring after the infusion, it was physically shown that the bacteria were adhered efficiently by both of the filters. CONCLUSION: The granular structured filter was found statistically and significantly more successful than the fibrial. Although the pore sizes of the filters were same - of which structural differences shown by SEM were the same - it would not be right to attribute the changes in the efficiencies to only structural differences. Using microbiological and physical proofs with regard to efficiency at the same time has been another important aspect of this experiment.

JUSTIFICATIVA E OBJETIVOS: Os filtros antibacterianos para cateter epidural são barreiras da analgesia/anestesia controlada pelo paciente para evitar a contaminação do local de inserção epidural. A eficácia desses filtros varia de acordo com o material e o tamanho dos poros. MÉTODO: A capacidade de aderência bacteriana dos dois filtros foi medida em experimento in vitro. Avaliamos a capacidade de aderência das cepas padrão de Staphylococcus aureus (ATCC 25923) e Pseudomonas aeruginosa (ATCC 27853) de dois filtros diferentes (Portex e Rusch), mas com poros do mesmo tamanho. Uma suspensão bacteriana grau 0,5 de McFarland foi colocada na bomba de analgesia controlada pelo paciente e filtrada a uma velocidade de 5 mL/h em infusão contínua por 48 horas e acumulada em frasco. Os dois filtros foram comparados com contagens de colônias de bactérias nos filtros e frascos. Ao mesmo tempo, os filtros e as bactérias aderidas foram monitorados com microscópio eletrônico de varredura. RESULTADOS: O exame dos filtros por microscópico eletrônico mostrou que a estrutura do filtro Portex era granulada e a do filtro Rusch fibrilar. A contagem de colônias do cateter e do frasco mostrou que ambos os filtros tinham uma capacidade de adesão bacteriana significativa (p < 0,001). Após a infusão da suspensão bacteriana, as contagens de colônias mostraram que o filtro Portex foi mais eficiente (p < 0,001). Não houve qualquer diferença entre as adesões de bactérias S. aureus e P. aeruginosa. Na monitoração por MEV após a infusão, ficou fisicamente evidente que as bactérias foram aderidas de modo eficaz por ambos os filtros. CONCLUSÃO: O filtro com estrutura granular foi estatística e significativamente mais bem- sucedido do que o filtro com estrutura fibrilar. Embora o tamanho dos poros dos filtros fosse igual - as diferenças estruturais mostradas pelo MEV eram semelhantes -, não seria justo atribuir as alterações de eficiência apenas às diferenças estruturais. O uso ao mesmo tempo de provas microbiológicas e físicas para avaliar a eficácia foi outro aspecto importante deste experimento.

The Escitalopram versus Electric Current Therapy for Treating Depression Clinical Study (ELECT-TDCS): rationale and study design of a non-inferiority, triple-arm, placebo-controlled clinical trial / Estudo clínico Escitalopram versus Eletroterapia no Tratamento da Depressão (ELECT-TDCS): racional e desenho de estudo de um ensaio de não inferioridade, de três braços, placebo-controlado

CONTEXT AND OBJECTIVE: Major depressive disorder (MDD) is a common psychiatric condition, mostly treated with antidepressant drugs, which are limited due to refractoriness and adverse effects. We describe the study rationale and design of ELECT-TDCS (Escitalopram versus Electric Current Therapy for Treating Depression Clinical Study), which is investigating a non-pharmacological treatment known as transcranial direct current stimulation (tDCS). DESIGN AND SETTING: Phase-III, randomized, non-inferiority, triple-arm, placebo-controlled study, ongoing in São Paulo, Brazil. METHODS: ELECT-TDCS compares the efficacy of active tDCS/placebo pill, sham tDCS/escitalopram 20 mg/day and sham tDCS/placebo pill, for ten weeks, randomizing 240 patients in a 3:3:2 ratio, respectively. Our primary aim is to show that tDCS is not inferior to escitalopram with a non-inferiority margin of at least 50% of the escitalopram effect, in relation to placebo. As secondary aims, we investigate several biomarkers such as genetic polymorphisms, neurotrophin serum markers, motor cortical excitability, heart rate variability and neuroimaging. RESULTS: Proving that tDCS is similarly effective to antidepressants would have a tremendous impact on clinical psychiatry, since tDCS is virtually devoid of adverse effects. Its ease of use, portability and low price are further compelling characteristics for its use in primary and secondary healthcare. Multimodal investigation of biomarkers will also contribute towards understanding the antidepressant mechanisms of action of tDCS. CONCLUSION: Our results have the potential to introduce a novel technique to the therapeutic arsenal of treatments for depression. .

CONTEXTO E OBJETIVO: O transtorno depressivo maior (TDM) é uma condição psiquiátrica comum, tratada com medicamentos antidepressivos, os quais são limitados devido à refratariedade e efeitos adversos. Descrevemos o racional e o desenho do Estudo Clínico Escitalopram versus Eletroterapia no Tratamento da Depressão (ELECT-TDCS), que investiga um tratamento não farmacológico, conhecido como estimulação transcraniana por corrente contínua (ETCC). DESENHO E LOCAL: Ensaio de fase III, randomizado, de não inferioridade, de três braços, placebo-controlado, em execução em São Paulo, Brasil. MÉTODOS: O estudo compara a eficácia da ETCC ativa/pílula placebo, ETCC simulada/escitalopram 20 mg/dia e ETCC simulada/pílula placebo durante 10 semanas, randomizando 240 pacientes em uma proporção 3:3:2, respectivamente. O objetivo principal é demostrar que a ETCC não é inferior ao escitalopram com uma margem de não inferioridade de pelo menos 50% do efeito de escitalopram em relação ao placebo. Como objetivos secundários, investigamos biomarcadores como polimorfismos genéticos, marcadores séricos, excitabilidade cortical motora, variabilidade da frequência cardíaca e neuroimagem. RESULTADOS: Provar que ETCC é igualmente eficaz a antidepressivos teria um tremendo impacto na psiquiatria clínica, uma vez que a ETCC é praticamente isenta de efeitos adversos. Sua facilidade de uso, portabilidade e preço baixo são outras características atraentes para uso na atenção primária e secundária de saúde. A investigação multimodal de biomarcadores também contribuirá para a compreensão dos mecanismos de ação antidepressivos da ETCC. CONCLUSÃO: Os nossos resultados podem introduzir uma nova técnica no arsenal terapêutico do tratamento da depressão. .

Effect of aerobic training on EEG alpha asymmetry and depressive symptoms in the elderly: a 1-year follow-up study

The effect of physical exercise on the treatment of depressive elderly adults has not been investigated thus far in terms of changes in cortical hemispheric activity. The objective of the present study was to identify changes in depressive symptoms, quality of life, and cortical asymmetry produced by aerobic activity. Elderly subjects with a diagnosis of major depressive disorder (DSM-IV) were included. Twenty patients (70 percent females, 71 ± 3 years) were divided into an exercise group (pharmacological treatment plus aerobic training) and a control group (undergoing pharmacological treatment) in a quasi-experimental design. Pharmacological treatment was maintained stable throughout the study (antidepressants and anxiolytics). Subjects were evaluated by depression scales (Beck Depression Inventory, Hamilton Depression Rating Scale, Montgomery-Asberg Depression Rating Scale) and the Short Form Health Survey-36, and electroencephalographic measurements (frontal and parietal alpha asymmetry) before and after 1 year of treatment. After 1 year, the control group showed a decrease in cortical activity on the right hemisphere (increase of alpha power), which was not observed in the exercise group. The exercise group showed a significant decrease of depressive symptoms, which was not observed in the control group. This result was also accompanied by improved treatment response and remission rate after 1 year of aerobic exercise associated with treatment. This study provides support for the effect of aerobic training on alpha activity and on depressive symptoms in elderly patients. Exercise facilitates the treatment of depressive elderly adults, leading to clinical and physical improvement and protecting against a decrease in cortical activity.

Neuromodulation approaches for the treatment of major depression: challenges and recommendations from a working group meeting / Estratégias de neuromodulação para o tratamento da depressão maior: desafios e recomendações de uma força-tarefa

The use of neuromodulation as a treatment for major depressive disorder (MDD) has recently attracted renewed interest due to development of other non-pharmacological therapies besides electroconvulsive therapy (ECT) such as transcranial magnetic stimulation (TMS), transcranial direct current stimulation (tDCS), deep brain stimulation (DBS), and vagus nerve stimulation (VNS). METHOD: We convened a working group of researchers to discuss the updates and key challenges of neuromodulation use for the treatment of MDD. RESULTS: The state-of-art of neuromodulation techniques was reviewed and discussed in four sections: [1] epidemiology and pathophysiology of MDD; [2] a comprehensive overview of the neuromodulation techniques; [3] using neuromodulation techniques in MDD associated with non-psychiatric conditions; [4] the main challenges of neuromodulation research and alternatives to overcome them. DISCUSSION: ECT is the first-line treatment for severe depression. TMS and tDCS are strategies with a relative benign profile of side effects; however, while TMS effects are comparable to antidepressant drugs for treating MDD; further research is needed to establish the role of tDCS. DBS and VNS are invasive strategies with a possible role in treatment-resistant depression. In summary, MDD is a chronic and incapacitating condition with a high prevalence; therefore clinicians should consider all the treatment options including invasive and non-invasive neuromodulation approaches.

O uso de técnicas de neuromodulação para o tratamento do transtorno depressivo maior (TDM) tem despertado um renovado interesse nos últimos anos com o desenvolvimento de outras intervenções não-farmacólogicas além da eletroconvulsoterapia (ECT), como a estimulação magnética transcraniana (EMT), a estimulação transcraniana por corrente continua (ETCC), a estimulação cerebral profunda (DBS) e a estimulação de nervo vago (VNS). MÉTODO: Nós organizamos um grupo de trabalho com vários pesquisadores para discutir os avanços recentes e os principais desafios para o uso da neuromodulação no tratamento do TDM. RESULTADOS: O estado-da-arte da neuromodulação foi revisado e discutido em quatro seções: [1] epidemiologia e fisiopatologia do TDM; [2] uma revisão das técnicas de neuromodulação; [3] o uso das técnicas de neuromodulação na depressão que ocorre associada ou em virtude de condições não-psiquiátricas; [4] os principais desafios da pesquisa na neuromodulação e alternativas para superá-los. DISCUSSÃO: ECT é o tratamento de primeira linha para depressão grave. EMT e ETCC são estratégias com um perfil benigno de efeitos adversos; contudo, enquanto os efeitos da EMT são comparáveis ao das drogas antidepressivas para o tratamento da TDM, a eficácia da ETCC ainda precisa ser estabelecida por mais pesquisas clínicas. DBS e VNS são intervenções invasivas com um papel possível para a depressão refratária. Em resumo, TDM é uma condição crônica, incapacitante e de alta prevalência; portanto na prática clínica todas as opções de tratamento possíveis, incluindo as farmacológicas e não-farmacológicas, devem ser consideradas.

Diretrizes da World Federation of Societies of Biological Psychiatry (WFSBP) para tratamento biológico de transtornos depressivos unipolares, 2ª parte: tratamento de manutenção do transtorno depressivo maior e tratamento dos transtornos depressivos crônicos e das depressões subliminares / World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for biological treatment of unipolar depressive disorders, part 2: maintenance treatment of major depressive disorder and treatment of chronic depressive disorders and subthreshold depressions

Estas diretrizes práticas para o tratamento biológico de transtornos depressivos unipolares foram desenvolvidas por uma Força-Tarefa internacional da Federação Mundial de Sociedades de Psiquiatria Biológica (WFSBP). O objetivo ao desenvolver tais diretrizes foi rever sistematicamente todas as evidências existentes referentes ao tratamento de transtornos depressivos unipolares e produzir uma série de recomendações práticas com significado clínico e científico, baseadas nas evidências existentes. Têm como objetivo seu uso por todos os médicos que atendam e tratem pacientes com essas afecções. Os dados usados para o desenvolvimento das diretrizes foram extraídos primariamente de várias diretrizes e painéis nacionais de tratamento para transtornos depressivos, bem como de metanálises e revisões sobre a eficácia dos antidepressivos e outras intervenções de tratamento biológico identificadas por uma busca no banco de dados MEDLINE e Cochrane Library. A literatura identificada foi avaliada quanto à força das evidências sobre sua eficácia e, então, categorizada em quatro níveis de evidências (A a D). Esta primeira parte das diretrizes abrange definição, classificação, epidemiologia e evolução dos transtornos depressivos unipolares, bem como tratamento das fases aguda e de manutenção. As diretrizes se referem primariamente ao tratamento biológico (incluindo antidepressivos, outros medicamentos psicofarmacológicos e hormonais, eletroconvulsoterapia, fototerapia, estratégias terapêuticas complementares e novas) de adultos jovens e também, embora em menor grau, de crianças, adolescentes e adultos idosos.

These practice guidelines for the biological treatment of unipolar depressive disorders were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBP). The goal for developing these guidelines was to systematically review all available evidence pertaining to the treatment of the complete spectrum of unipolar depressive disorders, and to produce a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating patients with these conditions. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for depressive disorders, as well as from meta-analyses and reviews on the efficacy of antidepressant medications and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and was then categorized into four levels of evidence (A-D). The first part of these WFSBP guidelines on unipolar depressive disorders covered the acute and continuation treatment of major depressive disorder (Bauer et al., 2002). This second part of the guidelines covers the management of the maintenance-phase treatment of major depressive disorder, as well as the treatment of chronic and subthreshold depressive disorders (dysthymic disorder, double depression, minor depressive disorder and recurrent brief depression). These guidelines are primarily concerned with thebiological treatment (including antidepressants, lithium, other psychopharmacological and hormonal medications, and electroconvulsive therapy) of young adults and also, albeit to a lesser extent, children, adolescents and older adults.