A Qualitative Study on Traumatic Experiences of Suicide Survivors.

The suicide of a loved one can be a traumatic experience. The objective of this study was to investigate trauma-related experiences of suicide survivors. This is a qualitative study with people who had recently lost a family member or a close one to suicide, conducted at least two months after the event. Forty-one participants agreed to take part in the study and were interviewed. The interviewees' perception was that suicide brought harm, symptoms, and suffering. Traumatic experiences can begin immediately after the event, with many reporting symptoms lasting many months and persistent impact, both personal and to the family. Postvention models after suicide should incorporate such findings, and investigate trauma consistently.

Factors Associated With Seizure Adequacy Along the Course of Electroconvulsive Therapy.

OBJECTIVES: Eliciting a generalized seizure is essential to electroconvulsive therapy (ECT), but there is still a need to understand how patient and session variables interact to generate a seizure of adequate quality. Here, we investigate factors associated with motor seizure length as a measure of quality in a large database of patients who underwent ECT. METHODS: This is a retrospective cohort including data from all adult inpatients who underwent ECT at a university hospital in Brazil from 2009 to 2015. We used linear mixed models to investigate the effects of patient, session, and medication on seizure length. RESULTS: Session information was available for 387 patients, a total of 3544 sessions and 4167 individual stimulations. Multiple stimulations were necessary in 12.4% of sessions. Median seizure length was 30 seconds. Seizure length was directly correlated with stimulus dosage and inversely correlated with the session number, patient age, prescription of anticonvulsants in the day before and ß-blockers during the session, and the thiopental dose. Use of benzodiazepines was not associated with a shorter seizure duration, irrespective of dose. CONCLUSIONS: We demonstrate here how motor seizure length evolves during a course of ECT. With a large number of sessions, we are able to integrate a host of factors in a prediction model. Seizure quality was influenced by a number of the studied factors, many of which are potentially modifiable and could be assessed before initiating and handled during treatment.

Characteristics of suicides of young people in Porto Alegre, Southern Brazil, from 2010 to 2016.

The purpose of this study was to describe demographic, toxicological, criminal, and medicolegal characteristics of suicides of young people aged up to 24 years examined by the Porto Alegre Medicolegal Office, from 2010 to 2016. This cross-sectional study collected data from the Porto Alegre Medicolegal Office and the Rio Grande do Sul State Police Department. The information was obtained from death certificates, toxicological analyses and police reports. Rates were calculated according to sex and age range (under 15 years old, 15 to 19 years old, and 20 to 24 years old) for comparing local with national data. There were 143 people who died by suicide in the period, 120 males and 23 females. Hanging was the most frequently used method, but in the range of 10 to 14 years old, firearm use was the predominant method. Fifty percent of male victims and 30% of female victims had some criminal history. Suicide rates in the study groups generally followed national trends. The relative frequency of suicide by firearm in this study diverged from international findings, as it was relatively more frequent in children under 15 years old and less frequent in older ranges. If confirmed, the finding draws attention to access to firearms in this age range. In older age ranges, adolescents and young adults were frequently involved in the criminal system. This finding may be useful for planning interventions involving both mental health education and screening for problems that may be associated with criminal involvement.

Mediator effects of parameters of inflammation and neurogenesis from a N-acetyl cysteine clinical-trial for bipolar depression.

OBJECTIVE: This study aimed to explore effects of adjunctive treatment with N-acetyl cysteine (NAC) on markers of inflammation and neurogenesis in bipolar depression. METHODS: This is a secondary analysis of a placebo-controlled randomised trial. Serum samples were collected at baseline, week 8, and week 32 of the open-label and maintenance phases of the clinical trial to determine changes in interleukin (IL)-6, IL-8, IL-10, tumour necrosis factor-α (TNF-α), C-reactive protein (CRP) and brain-derived neurotrophic factor (BDNF) following adjunctive NAC treatment, and to explore mediation and moderator effects of the listed markers. RESULTS: Levels of brain-derived neurotrophic factor (BDNF), tumour necrosis factor-α (TNF-α), C-reactive protein (CRP), interleukins (IL) -6, 8, or 10 were not significantly changed during the course of the trial or specifically in the open-label and maintenance phases. There were no mediation or moderation effects of the biological factors on the clinical parameters. CONCLUSION: The results suggest that these particular biological parameters may not be directly involved in the therapeutic mechanism of action of adjunctive NAC in bipolar depression.

"Why throw away something useful?": Attitudes and opinions of people treated for bipolar disorder and their relatives on organ and tissue donation.

In regard to mental illness, brain donation is essential for the biological investigation of central pathology. Nevertheless, little is known about the thoughts of people with mental disorders on tissue donation for research. Here, our objective was to understand the attitudes and opinions of people treated for bipolar disorder and their relatives regarding donation in general, and particularly donation for research. This is a qualitative study that used in-depth interviews to determine the thoughts of participants regarding tissue donation for research. Theoretical sampling was used as a recruitment method. Grounded theory was used as a framework for content analyses of the interviews. A semi-structured interview guide was applied with the topics: donation in general; donation for research; mental health and body organs; opinion regarding donation; feelings aroused by the topic. Although all participants were aware of organ donation for transplant, they were surprised that tissue could be donated for research. Nevertheless, once they understood the concept they were usually in favor of the idea. Although participants demonstrated a general lack of knowledge on donation for research, they were willing to learn more and viewed it as a good thing, with altruistic reasons often cited as a motive for donation. We speculate that bridging this knowledge gap may be a fundamental step towards a more ethical postmortem tissue donation process.

Antioxidant treatments for schizophrenia.

BACKGROUND: There is accumulating evidence that progressive changes in brain structure and function take place as schizophrenia unfolds. Among many possible candidates, oxidative stress may be one of the mediators of neuroprogression, grey matter loss and subsequent cognitive and functional impairment. Antioxidants are exogenous or endogenous molecules that mitigate any form of oxidative stress or its consequences. They may act from directly scavenging free radicals to increasing anti-oxidative defences. There is evidence that current treatments impact oxidative pathways and may to some extent reverse pro-oxidative states in schizophrenia. The existing literature, however, indicates that these treatments do not fully restore the deficits in antioxidant levels or restore levels of oxidants in schizophrenia. As such, there has been interest in developing interventions aimed at restoring this oxidative balance beyond the benefits of antipsychotics in this direction. If antioxidants are to have a place in the treatment of this serious condition, the relevant and up-to-date information should be available to clinicians and investigators. OBJECTIVES: To evaluate the effect of antioxidants as add-on treatments to standard antipsychotic medication for improving acute psychotic episodes and core symptoms, and preventing relapse in people with schizophrenia. SEARCH METHODS: We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials which is based on regular searches of CINAHL, BIOSIS, AMED, Embase, PubMed, MEDLINE, PsycINFO, and registries of clinical trials. There are no language, time, document type, or publication status limitations for inclusion of records in the register. We ran this search in November 2010, and again on 8 January 2015. We also inspected references of all identified studies for further trials and contacted authors of trials for additional information. SELECTION CRITERIA: We included reports if they were randomised controlled trials (RCTs) involving people with schizophrenia who had been allocated to either a substance with antioxidant potential or to a placebo as an adjunct to standard antipsychotic treatment. DATA COLLECTION AND ANALYSIS: We independently extracted data from these trials and we estimated risk ratios (RR) or mean differences (MD), with 95% confidence intervals (CI). We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. MAIN RESULTS: The review includes 22 RCTs of varying quality and sample size studying Ginkgo biloba, N-acetyl cysteine (NAC), allopurinol, dehydroepiandrosterone (DHEA), vitamin C, vitamin E or selegiline. Median follow-up was eight weeks. Only three studies including a minority of the participants reported our a priori selected primary outcome of clinically important response. Short-term data for this outcome (measured as at least 20% improvement in scores on Positive and Negative Syndrome Scale (PANSS)) were similar (3 RCTs, n = 229, RR 0.77, 95% CI 0.53 to 1.12, low quality evidence). Studies usually reported only endpoint psychopathology rating scale scores. Psychotic symptoms were lower in those using an adjunctive antioxidant according to the PANSS ( 7 RCTS, n = 584, MD -6.00, 95% CI -10.35 to -1.65, very low quality evidence) and the Brief Psychiatric Rating Scale (BPRS) (8 RCTS, n = 843, MD -3.20, 95% CI -5.63 to -0.78, low quality evidence). There was no overall short-term difference in leaving the study early (16 RCTs, n = 1584, RR 0.73, 95% CI 0.48 to 1.11, moderate quality evidence), or in general functioning (2 RCTs, n = 52, MD -1.11, 95% CI -8.07 to 5.86, low quality evidence). Adverse events were generally poorly reported. Three studies reported useable data for 'any serious adverse effect', results were equivocal (3 RCTs, n = 234, RR 0.65, 95% CI 0.19 to 2.27, low quality evidence). No evidence was available for relapse, quality of life or service use. AUTHORS' CONCLUSIONS: Although 22 trials could be included in this review, the evidence provided is limited and mostly not relevant to clinicians or consumers. Overall, although there was low risk of attrition and selective data reporting bias within the trials, the trials themselves were not adequately powered and need more substantial follow-up periods. There is a need for larger trials with longer periods of follow-up to be conducted. Outcomes should be meaningful for those with schizophrenia, and include measures of improvement and relapse (not just rating scale scores), functioning and quality of life and acceptability and, importantly, safety data.

Clozapine and the Course of Bipolar Disorder in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD).

OBJECTIVE: The potential of clozapine in severe bipolar disorder is suggested by its efficacy in refractory schizophrenia, but the evidence is limited thus far. This report utilizes data from the standard care pathway of the Systematic Treatment Enhancement Program to examine the clinical impact of clozapine in bipolar disorder, comparing it to two groups, one that received olanzapine and an additional group that received neither drug. METHOD: A total of 4,032 outpatients were available for this analysis. Groups for longitudinal analyses are based on the medication used at each visit. Outcomes assessed were clinical status, symptoms subscales, hospitalizations, and death. We utilized mixed models and generalized estimating equations to adjust for baseline differences and investigate longitudinal differences in symptoms, clinical status, and hospitalization rates between groups. RESULTS: During the study, 1.1% (n = 43) of the patients used clozapine at any time. Those on clozapine had significantly fewer manic and depressive symptoms during follow-up as compared with those on neither clozapine nor olanzapine, while those on olanzapine had more symptoms. The use of clozapine was not associated with an increased risk of hospitalization. No deaths were recorded for clozapine group during the trial. CONCLUSIONS: Although prescribed to very few patients, the impact of clozapine was notable, with fewer symptoms in patients who had more severe illnesses at baseline. Clozapine could prove to be as successful an intervention for late-stage bipolar disorder as it has been in schizophrenia.

Psychiatric and substance-use comorbidities associated with lifetime crack cocaine use in young adults in the general population.

OBJECTIVE: To assess the association between lifetime crack cocaine use and psychiatric (post-traumatic stress disorder, current depression, current dysthymia, generalized anxiety disorder, panic disorder with agoraphobia, social phobia, as well as SRQ scores and suicide risk) and substance-use disorders (tobacco, alcohol, cannabis, cocaine, amphetamine, inhalants, sedatives, hallucinogens and opioids) in youth in the general population of the city of Pelotas, RS. METHOD: This was a cross-sectional population-based study, involving 1560 participants between 18 and 24 ears old. Lifetime substance use and abuse were investigated using the ASSIST inventory. Psychiatric comorbidities were assessed using the Mini-International Neuropsychiatric Interview and symptoms of common mental disorders were evaluated with the Self-Reported Questionnaire (SRQ). RESULTS: The prevalence of lifetime crack cocaine use in the sample was 2.5%. Its use was associated with total SRW scores and the presence of post-traumatic stress disorder, antisocial personality disorder and suicide risk in the final regression model. Tobacco, alcohol, cannabis, cocaine, amphetamine and cocaine dependence were also associated with lifetime use of crack cocaine. DISCUSSION: Youth with a history of crack cocaine use had a higher prevalence of psychiatric conditions such as post-traumatic stress disorder, as well as an increased risk of tobacco, alcohol, cannabis, cocaine, amphetamine and inhalant use and dependence.

Violent and sexual behaviors and lifetime use of crack cocaine: a population-based study in Brazil.

OBJECTIVE: To estimate the prevalence of lifetime use of crack cocaine and to assess associations with violent and sexual behaviors in young adults selected from the general population of Pelotas, Southern Brazil. METHODS: This cross-sectional population-based study included 1,560 participants aged 18-24 years. The use of alcohol and other substances, including crack cocaine, was assessed using the alcohol, smoking and substance involvement screening test. Other variables included violent behaviors, firearm possession, and sexual risk behaviors. The frequency of antisocial personality disorder was also investigated. Associations were analyzed using a crude model and models adjusted for sex, social class, and the use of snorted cocaine. RESULTS: Lifetime prevalence of crack cocaine use was 2.51 %, and it was higher among males and individuals coming from more vulnerable social classes (D or E). In the final multivariate models, lifetime use of crack cocaine was associated with episodes of aggression and firearm possession, as well as with a higher chance of not having used condom in the last sexual intercourse. In less conservative models, crack cocaine use was associated with other violent and sexual risk behaviors. DISCUSSION: The strong association observed between lifetime use of crack cocaine and different violent and sexual risk behaviors underscores relevant characteristics of people who use crack cocaine. Improving our understanding of possible causal chains leading to such associations should be a priority in future studies.

A grounded theory on acceptance of diagnosis as a pathway to recovery in bipolar disorder.

The recovery process in bipolar disorder is a subjective and multidimensional experience that seeks to develop new meanings and purposes for living a satisfying life despite the limitations imposed by the disorder. Thus, this qualitative study aimed to explore the perceptions of recovery and the meanings attributed by individuals undergoing treatment for bipolar disorder to the elements considered relevant in this process. Semi-structured interviews with open-ended questions were conducted to explore the experiences and perspectives of recovery in individuals undergoing treatment for bipolar disorder. Grounded Theory was used as the method for qualitative analysis. The study included 26 participants aged between 18 and 65 years. Based on the analysis of participant reports, we identified two main themes: living with the illness and what it means to be in recovery. The perception of recovery is an individual process and can differ from the medical model. Participants suggest that accepting the diagnosis of bipolar disorder and finding meaning in life are essential to their recovery. They also describe how mental health professionals can facilitate or hinder this process. Understanding patients' perceptions can facilitate access to healthcare services and treatment adherence.

Daytime sleepiness, sleep disturbance and functioning impairment in bipolar disorder.

OBJECTIVE: To verify the prevalence and clinical impact of excessive daytime sleepiness (EDS) in outpatients with bipolar disorder. METHODS: Eighty-one outpatients with bipolar disorder and 79 healthy control subjects were recruited. Patients were required not to be acutely manic or depressed. We used the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index and the Functioning Assessment Short Test to assess sleepiness, sleep problems and functioning, respectively. RESULTS: Patients had a higher prevalence of sleepiness (40%) than the control group (18%). Sleepiness and sleep disturbance had independent impacts on disability in the multivariable model. CONCLUSIONS: This study suggests that EDS is a relevant clinical dimension in patients with bipolar disorder. It is a frequent symptom that often overlaps with other sleep disturbances. This study also reveals that once present it has the potential to increase functional impairment.

Relative impact of diagnosis and clinical stage on response to electroconvulsive therapy: a retrospective cohort.

OBJECTIVE: Electroconvulsive therapy (ECT) is commonly indicated for refractory psychiatric disorders. However, response comparison across diagnoses is scantly investigated. Here, we aimed to evaluate the relative impact of diagnosis and clinical staging as response predictors in a cross-diagnostic sample. METHODS: We investigate, in a retrospective cohort of adult inpatients (N=287) who underwent at least six sessions of ECT, predictors of complete response (a clinical global impression of 1) to ECT. We use adjusted regression models to estimate the impact of clinical diagnosis and staging on complete response and dominance analysis to assess the relative importance of these predictors. RESULTS: Those with a depressive episode as a primary indication for treatment were more likely than all the other groups to have complete improvement, while those with psychosis were the least likely; clinical stage had a significant influence on outcome in all diagnoses. A diagnosis of psychosis stood as the strongest predictor of non-response. CONCLUSION: An indication of ECT for psychosis (mostly schizophrenia) had a dominant impact in our cohort, indicating a worse chance of response. We also demonstrate that clinical staging can aggregate information on response to electroconvulsive therapy that is independent of clinical diagnosis.

Gender-related and non-gender-related female homicide in Porto Alegre, Brazil, from 2010 to 2016.

Female homicide is a global phenomenon with a higher prevalence in countries in Asia, Africa, and the Americas. Life expectancy in Brazil is compromised by the high risk of death from male and female homicides, a growing social problem. This study aimed to integrate different public datasets and describe the sociodemographic, criminal, and medicolegal characteristics of the homicides of girls and women occurring in Porto Alegre, southern Brazil, from 2010 to 2016. The data were obtained from autopsy reports, police reports, and records from crime scenes. During this period, there was a significant increase in overall standardized rates of female homicides (4.98 to 10.85), with a pronounced increase in non-gender-related deaths, especially due to urban violence, such as involvement in drug trafficking and other crimes and robbery resulting in death. Young (15-29 years of age), non-White women were the most affected. Increased female homicide rates due to non-gender-related factors is a new and worrying phenomenon in Brazil. Obtaining specific data on the profile of victims and characteristics of violence is a crucial step in facing the problem and directing public policies.

Peripheral oxidative damage in early-stage mood disorders: a nested population-based case-control study.

Systemic toxicity is a relevant dimension of pathophysiology in bipolar disorder, and oxidative damage is one potential link between central and peripheral pathology. Although there is mounting evidence that chronic bipolar disorder is associated with oxidative stress, studies in the early stages of bipolar disorder are scarce, and heavily reliant on clinical in lieu of population studies. The objective of this study was to confirm leading hypotheses about the role of oxidative damage in bipolar disorder. To that end, we nested a case-control study in a population-based study of young adults aged 18-24 yr. After an initial psychopathology screen, all people with a lifetime history of (hypo)mania and matched controls underwent a structured diagnostic interview. This yielded a sample of 231 participants, in whom we measured serum protein carbonyl content (PCC) and thiobarbituric acid reactive substances (TBARS). People with bipolar disorder had higher PCC levels than healthy subjects. Those with major depression were not different from control subjects in either PCC or TBARS levels. Both bipolar disorder and major depression were associated with higher PCC levels in the a priori regression model controlling for possible confounders. These findings indicate that protein oxidative damage is present from early stages and can be seen as a sign of early illness activity in mood disorders.

Childhood trauma, impulsivity, and executive functioning in crack cocaine users.

BACKGROUND: The use of crack cocaine is a major public health concern in Brazil and internationally. Recent data suggest that childhood trauma is associated with worse outcomes among cocaine users. This study had the objective of evaluating the relationship of childhood trauma with executive functioning and impulsivity in outpatients with crack cocaine use disorders. METHODS: This is a cross-sectional study of 84 consecutive outpatients with a primary crack cocaine use disorder who sought treatment in Porto Alegre, Brazil. Childhood trauma was evaluated with the Childhood Trauma Questionnaire; executive functioning, with the Wisconsin Card Sorting Test; and impulsivity, with the Barratt Impulsivity Scale. RESULTS: Childhood trauma was strongly associated with executive dysfunction and impulsivity, even when controlled for possible confounders. CONCLUSIONS: Childhood trauma may be associated with executive dysfunction and impulsivity in crack cocaine users. The full impact of trauma needs to be further investigated in longitudinal studies.

A bidimensional solution for outcomes in bipolar disorder.

Although depressive symptoms have been consistently associated with lower quality of life and increased disability in bipolar disorder, their relation to manic symptoms is not as clear cut. A great overlap between these outcomes complicates the understanding of how they cluster together. We used exploratory factor analysis to clarify the relation between these constructs. We consecutively recruited 320 patients with bipolar disorder, and interviewers rated the Hamilton Depression and Anxiety Rating Scales, the Young Mania Rating Scale (YMRS), Clinical Global Impression (CGI), and the Global Assessment of Functioning (GAF). The self-rated Sheehan Disability Scale and the World Health Organization Quality of Life-BREF questionnaires were also collected. Two distinct and large dimensions emerged. Depression and anxiety, along with the self-rated scales, loaded in the first factor, whereas the YMRS, the GAF, and the CGI loaded in the second. These findings imply that evaluating self- and observer-rated outcomes may make up for a more thorough evaluation because each conveys unique illness information.

Socioeconomic and substance use changes in emerging adults and their relationship with mood disorders in a population-based cohort.

In this report, we aim to assess the interaction of bipolar disorder and major depressive disorder with the evolution of social roles, economic classification, and substance misuse in emerging adults. This is a longitudinal population-based study (n = 231 at baseline), in which participants were reassessed at a mean of 5 years after baseline. A structured clinical interview was used to diagnose the participants with bipolar disorder and major depression; a control group without mood disorders was included. Men with mood disorders were less likely to be married in the beginning of the study and less likely to work in the follow-up. Women with major depression were less likely to study and more likely to be in a lower economic class at the beginning of the study. In comparison, women with bipolar disorder were less likely to live with their parents and more likely to live with their children in the first wave of the study. Substance misuse was more likely in people with mood disorders, especially in men, and women with bipolar disorder had the highest likelihood in the follow-up. Albeit longitudinal analyses were limited by a possibly insufficient sample size and mediating mechanisms for change, such as stigma, were not explored, the study suggests sex-related specificities regarding the change in social roles and substance use in people with mood disorders. Emerging adults, especially those with mood disorders, are in a period of change and instability and at a greater risk for substance use and abuse.

Early illness progression in mood disorders: A population-based longitudinal study.

This study is aimed at assessing changes in functioning among young people from the general population with bipolar disorder and major depressive disorder over a period of five years. Specifically, we hypothesized that significant illness progression would take place during euthymia over time in bipolar disorder. We conducted a longitudinal study with 231 people, assessed at baseline and again at a five-year follow-up. A structured clinical interview was used to diagnose participants with mood disorders. A control group without mood disorders was also included. Functioning was assessed with the Functioning Assessment Short Test, and linear mixed models were used to analyze the effect of psychopathology on change in functioning. Mood disorders were associated with significant functional impairment, but functioning significantly improved in both groups over the 5-year follow-up period. Depressive episodes, however, were associated with worse functioning at follow-up, independently of depression severity. In contrast to our initial hypothesis, we found a worsening of functioning in a five-year period associated only with depressive episodes. This suggests that interventions focused on the prevention of mood episodes early in the course of illness may be particularly promising to reduce adverse functioning outcomes.

Correlates and impact of obsessive-compulsive comorbidity in bipolar disorder.

BACKGROUND: Anxiety morbidity in general is frequent and harmful in bipolar disorder. Little is known, however, whether obsessive-compulsive comorbidity entails particular effects. This report aims to evaluate the prevalence and impact of obsessive-compulsive disorder (OCD) comorbidity in a relatively large clinical sample of bipolar disorder, with other lifetime anxiety comorbidities used as a more rigorous control group. METHODS: A cross-sectional study in a consecutive clinical sample, with anxiety comorbidity derived from the intake Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, was conducted. Anxiety was assessed with the Hamilton Anxiety Rating Scale. The Young Mania Rating Scale and the Hamilton Depression Rating Scale were used to assess (hypo)manic and depressive symptoms. The domains of the WHOQOL BREF were used to evaluate quality of life. RESULTS: Lifetime prevalence of OCD comorbidity was 12.4%. No cases of OCD were detected during mania. Compared with subjects with no anxiety comorbidity, those with lifetime OCD were more likely to have a history of suicide attempts, rapid cycling, and alcohol dependence. Patients with OCD had a lower score on all domains of the WHOQOL. Compared with those with other lifetime anxiety disorders, those with OCD had more anxiety, which mediated a lower WHOQOL social domain. CONCLUSIONS: Bipolar disorder patients with obsessive-compulsive comorbidity have a number of indicators of an overall more severe illness. The presence of more anxiety symptoms and a lower social quality of life may be more specific features of the bipolar-OCD comorbidity.