portuguese | english Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2016: 2.049
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Reappraising the dimensional structure of the PTSD Checklist: lessons from the DSM-IV-based PCL-C
Michael E. Reichenheim; Aline G. Oliveira; Claudia L. Moraes; Evandro S. Coutinho; Ivan Figueira; Gustavo Lobato

OBJECTIVE: The dimensional structure of posttraumatic stress disorder (PTSD) has been extensively debated, but the literature is still inconclusive and contains gaps that require attention. This article sheds light on hitherto unvisited methodological issues, reappraising several key models advanced for the DSM-IV-based civilian version of the PTSD Checklist (PCL-C) as to their configural and metric structures. METHODS: The sample comprised 456 women, interviewed at 6-8 weeks postpartum, who attended a high-complexity facility in Rio de Janeiro, Brazil. Confirmatory factor analysis (CFA) and exploratory structural equation models (ESEM) were used to evaluate the dimensional structure of the PCL-C. RESULTS: The original three-factor solution was rejected, along with the four-factor structures most widely endorsed in the literature (PTSD-dysphoria and PTSD-numbing models). Further exploration supported a model comprised of two factors (re-experience/avoidance and numbing/hyperarousal). CONCLUSION: These findings are at odds with the dimensional structure proposed in both DSM-IV and DSM-5. This also entails a different presumption regarding the latent structure of PTSD and how the PCL should be operationalized.

Descriptors: posttraumatic stress disorder; psychometric tests/interviews; diagnosis and classification; epidemiology; women

Stress, trauma, and posttraumatic stress disorder in migrants: a comprehensive review
Lineth H.U. Bustamante; Raphael O. Cerqueira; Emilie Leclerc; Elisa Brietzke

OBJECTIVE: There is growing evidence supporting the association between migration and posttraumatic stress disorder (PTSD). Considering the growing population of migrants and the particularities of providing culturally sensitive mental health care for these persons, clinicians should be kept up to date with the latest information regarding this topic. The objective of this study was to critically review the literature regarding migration, trauma and PTSD, and mental health services. METHODS: The PubMed, SciELO, LILACS, and ISI Web of Science databases were searched for articles published in Portuguese, English, Spanish, or French, and indexed from inception to 2017. The following keywords were used: migration, mental health, mental health services, stress, posttraumatic stress disorder, and trauma. RESULTS: Migration is associated with specific stressors, mainly related to the migratory experience and to the necessary process of acculturation occurring in adaptation to the host country. These major stressors have potential consequences in many areas, including mental health. The prevalence of PTSD among migrants is very high (47%), especially among refugees, who experience it at nearly twice the rate of migrant workers. CONCLUSIONS: Mental health professionals must be trained to recognize and provide appropriate care for posttraumatic and/or stress-related disorders among migrants.

Descriptors: PTSD; migration; stress; trauma; mental health services

Plasma IL-17A levels in patients with late-life depression
Smita Saraykar; Bo Cao; Lucelia S. Barroso; Kelly S. Pereira; Laiss Bertola; Mariana Nicolau; Jessica D. Ferreira; Natalia S. Dias; Erica L. Vieira; Antonio L. Teixeira; Ana Paula M. Silv Breno S. Diniz

OBJECTIVE: A consistent body of research has confirmed that patients with major depressive disorder (MDD) have increased concentrations of pro-inflammatory cytokines, including IL-6, TNF-α, IL-1β, the soluble IL-2 receptor, and C-reactive protein, compared to controls; however, there is limited information on IL-17A in MDD. Moreover, information about IL-17A in older populations, i.e., patients with late-life depression (LLD), is conspicuously missing from the literature. The purpose of this study was to investigate the role of IL-17A in LLD. METHODS: A convenience sample of 129 individuals, 74 with LLD and 55 non-depressed controls, were enrolled in this study. The Mann-Whitney U test was used to compare plasma IL-17A levels between LLD and controls subjects, and Spearman's rank order correlation was used to investigate correlation of these levels with clinical, neuropsychological, and cognitive assessments. RESULTS: Plasma IL-17A levels were not statistically different between LLD patients and controls (p = 0.94). Among all subjects (LLD + control), plasma IL-17A did not correlate significantly with depressive symptoms (rho = -0.009, p = 0.92) but a significant correlation was observed with cognitive assessments (rho = 0.22, p = 0.01). CONCLUSION: Our findings do not support an association between plasma IL-17A levels and LLD. Nevertheless, IL-17A may be associated with cognitive impairment in LLD patients. If this finding is confirmed in future longitudinal studies, modulation of the T-helper 17 cell (Th17) immune response may be a treatment target for cognitive impairment in this population.

Descriptors: Depression; cytokines; cognitive impairment; immunology

Changes in energy and motor activity: core symptoms of bipolar mania and depression?
Elie Cheniaux; Rafael de A. da Silva; Cristina M. Santana; Alberto Filgueiras

OBJECTIVE: To evaluate how well symptom rating scales differentiate bipolar disorder (BD) episode types METHODS: One hundred and six patients with BD were followed for 13 years. At each visit, the following clinical scales were administered: Young Mania Rating Scale (YMRS), Hamilton Depression Scale (HAM-D) and Clinical Global Impressions scale for use in bipolar illness (CGI-BP). To perform a comparison between the affective states of BP, three time points in each patient's follow-up period were chosen for evaluation: the most severe manic episode, the most severe depressive episode, and the euthymic period with least symptoms. Canonical discriminant analyses (CDA) were performed to identify which symptoms best discriminated episodes. RESULTS: CDA revealed HAM-D was worse than YMRS and CGI-BP to discriminate mood states. The items evaluating increased motor activity in YMRS (2, increased motor activity/energy) and HAM-D (9, agitation) were the best to distinguish mania, depression, and euthymia. In contrast, HAM-D item8 (retardation) and the HAM-D and YMRS items related to mood symptoms were less important and precise. CONCLUSION: Higher levels of energy or activity should be considered a core symptom of mania. However, our results do not confirm the association between a decrease in energy or activity and depression. HAM-D probably does not assess motor activity adequately.

Descriptors: Bipolar disorder; discriminant analysis; motor activity; energy

Can parenting practices predict externalizing behavior problems among children with hearing impairment?
María J. Pino; Rosa A. Castillo; Antonio Raya; Javier Herruzo

OBJECTIVE: To identify possible differences in the level of externalizing behavior problems among children with and without hearing impairment and determine whether any relationship exists between this type of problem and parenting practices. METHODS: The Behavior Assessment System for Children was used to evaluate externalizing variables in a sample of 118 boys and girls divided into two matched groups: 59 with hearing disorders and 59 normal-hearing controls. RESULTS: Significant between-group differences were found in hyperactivity, behavioral problems, and externalizing problems, but not in aggression. Significant differences were also found in various aspects of parenting styles. A model for predicting externalizing behavior problems was constructed, achieving a predicted explained variance of 50%. CONCLUSION: Significant differences do exist between adaptation levels in children with and without hearing impairment. Parenting style also plays an important role.

Descriptors: Child psychiatry; families; child rearing; hearing loss; disruptive, impulse control, and conduct disorders

Dysfunctional eating behaviors, anxiety, and depression in Italian boys and girls: the role of mass media
Barbara Barcaccia; Viviana Balestrini; Angelo M. Saliani; Roberto Baiocco Francesco Mancini; Barry H. Schneider

OBJECTIVE: Extensive research has implicated identification with characters in mass media in the emergence of disordered eating behavior in adolescents. We explored the possible influence of the models offered by television (TV) on adolescents' body image, body uneasiness, eating-disordered behavior, depression, and anxiety. METHODS: Three hundred and one adolescents (aged 14-19) from southern Italy participated. They completed a questionnaire on media exposure and body dissatisfaction, the Eating Disorder Inventory-2, the Body Uneasiness Test, the Beck Depression Inventory, and the State-Trait Anxiety Inventory - Form Y. RESULTS: The main factors contributing to females' eating-disordered behaviors were their own desires to be similar to TV characters, the amount of reality and entertainment TV they watched, and the discrepancy between their perceptions of their bodies and those of TV characters. Friends' desire to be similar to TV characters contributed most to depression, anxiety, body uneasiness, and eating disorders for both males and females. CONCLUSION: Our data confirm that extensive watching of reality and entertainment TV correlates with eating-disordered behavior among females. Moreover, the well-known negative effects of the media on adolescents' eating-disordered behaviors may also be indirectly transmitted by friends who share identification with TV characters.

Descriptors: Adolescents; eating disorders; child psychiatry; women; gender differences

Support vector machine-based classification of neuroimages in Alzheimer's disease: direct comparison of FDG-PET, rCBF-SPECT and MRI data acquired from the same individuals
Luiz K. Ferreira; Jane M. Rondina; Rodrigo Kubo; Carla R. Ono; Claudia C. Leite; Jerusa Smid; Cassio Bottino; Ricardo Nitrini; Geraldo F. Busatto; Fabio L. Duran; Carlos A. Buchpiguel

OBJECTIVE: To conduct the first support vector machine (SVM)-based study comparing the diagnostic accuracy of T1-weighted magnetic resonance imaging (T1-MRI), F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and regional cerebral blood flow single-photon emission computed tomography (rCBF-SPECT) in Alzheimer's disease (AD). METHOD: Brain T1-MRI, FDG-PET and rCBF-SPECT scans were acquired from a sample of mild AD patients (n=20) and healthy elderly controls (n=18). SVM-based diagnostic accuracy indices were calculated using whole-brain information and leave-one-out cross-validation. RESULTS: The accuracy obtained using PET and SPECT data were similar. PET accuracy was 68B71% and area under curve (AUC) 0.77B0.81; SPECT accuracy was 68B74% and AUC 0.75B0.79, and both had better performance than analysis with T1-MRI data (accuracy of 58%, AUC 0.67). The addition of PET or SPECT to MRI produced higher accuracy indices (68B74%; AUC: 0.74B0.82) than T1-MRI alone, but these were not clearly superior to the isolated neurofunctional modalities. CONCLUSION: In line with previous evidence, FDG-PET and rCBF-SPECT more accurately identified patients with AD than T1-MRI, and the addition of either PET or SPECT to T1-MRI data yielded increased accuracy. The comparable SPECT and PET performances, directly demonstrated for the first time in the present study, support the view that rCBF-SPECT still has a role to play in AD diagnosis.

Descriptors: Alzheimer's disease; support vector machine; MRI; FDG-PET; SPECT

Childhood emotional and behavior problems and their associations with cesarean delivery
Erigene Rutayisire; Xiaoyan Wu; Kun Huang; Shuman Tao; Yunxiao Chen; Fangbiao Tao

OBJECTIVE: To determine the prevalence of childhood emotional and behavioral problems and examine their associations with cesarean delivery. METHODS: Our sample consisted of 8,900 preschoolers from 35 kindergartens in four cities in East China. Parents completed the Strengths and Difficulties Questionnaire (SDQ) and provided other information. Children's emotional and behavioral problems were assessed using five subscales of the SDQ. Mode of delivery was classified as vaginal or cesarean section (CS); in sub-analyses, we divided CS into elective or emergency delivery. Logistic regression was used to examine associations. RESULTS: A total of 1,209 (13.6%) children had a total SDQ score within abnormal range; 25.5% had peer problems within abnormal range, 9.0% had abnormal emotional symptoms, 13.9% had abnormal conduct problems, 18.9% had abnormal hyperactivity problems, and 16.2% were rated abnormal in pro-social behavior. Overall, 67.3% of the children who participated were delivered by CS. In fully adjusted analysis, CS was significantly associated with abnormal total SDQ score (OR = 1.27; 95%CI 1.10-1.46; p < 0.05) and pro-social behavior (OR = 1.27; 95%CI 1.12-1.45; p < 0.0001). No significant association was found between CS and risk of having conduct problems (OR 1.13; 95%CI 0.98-1.29), peer problems (OR 1.11; 95%CI 0.99-1.24), hyperactivity (OR 1.02; 95%CI 0.91-1.15), or emotional problems (OR 1.06; 95%CI 0.90-1.24). CONCLUSION: In this sample, CS was associated with risk of behavioral problems, but not with emotional problems. Further research is needed to better understand these associations.

Descriptors: Problem behavior; cesarean section; delivery mode; pregnancy; preschool children

Gender incongruence: a comparative study using ICD-10 and DSM-5 diagnostic criteria
Bianca M. Soll; Rebeca Robles-García; Angelo Brandelli-Costa; Daniel Mori; Andressa Mueller; Anna M. Vaitses-Fontanari; Dhiordan Cardoso-da-Silva; Karine Schwarz; Maiko Abel-Schneider; Alexandre Saadeh Maria-Inês-Rodrigues Lobato

OBJECTIVE: To compare the presence of criteria listed in the DSM-5 and ICD-10 diagnostic manuals in a Brazilian sample of transgender persons seeking health services specifically for physical transition. METHODS: This multicenter cross-sectional study included a sample of 103 subjects who sought services for gender identity disorder in two main reference centers in Brazil. The method involved a structured interview encompassing the diagnostic criteria in the two manuals. RESULTS: The results revealed that despite theoretical disagreement about the criteria, the manuals overlap regarding diagnosis confirmation; the DSM-5 was more inclusive (97.1%) than the ICD-10 (93.2%) in this population. CONCLUSIONS: Although there is no consensus on diagnostic criteria on transgenderism in the diversity of social and cultural contexts, more comprehensive diagnostic criteria are evolving due to society's increasing inclusivity.

Descriptors: Diagnosis and classification; gender differences; minority issues and cross-cultural psychiatry; history of psychiatry; social and political issues

Cardiovascular risk and bipolar disorder: factors associated with a positive coronary calcium score in patients with bipolar disorder type 1
Aline R. Wageck; Felipe S. Torres; Clarissa S. Gama; Dayane S. Martins; Ellen Scotton; Ramiro Reckziegel; Monise Costanzi Regis G. Rosa; Flávio Kapczinski; Maurício Kunz

OBJECTIVE: Cardiovascular disease is the leading cause of death in patients with bipolar disorder. The aim of this study was to evaluate the factors associated with positive coronary calcium score (CCS) in individuals with bipolar disorder type 1. METHODS: Patients from the Bipolar Disorder Program at Hospital de Clínicas de Porto Alegre, Brazil, underwent computed tomography scanning for calcium score measurement. Clinical and sociodemographic variables were compared between patients according to their CCS status: negative (CCS = 0) or positive (CCS > 0). Poisson regression analysis was used to examine the association of CCS with number of psychiatric hospitalizations. RESULTS: Out of 41 patients evaluated, only 10 had a positive CCS. Individuals in the CCS-positive group were older (55.2±4.2 vs. 43.1±10.0 years; p = 0.001) and had more psychiatric hospitalizations (4.7±3.0 vs. 2.6±2.5;p = 0.04) when compared with CCS-negative subjects. The number of previous psychiatric hospitalizations correlated positively with CCS (p < 0.001). CONCLUSION: Age and number of psychiatric hospitalizations were significantly associated with higher CCS, which might be a potential method for diagnosis and stratification of cardiovascular disease in bipolar patients. There is a need for increased awareness of risk assessment in this population.

Descriptors: Bipolar disorder; cardiovascular diseases; diagnostic techniques; cardiovascular; coronary disease

Screening for common mental disorders using the SRQ-20 in Brazil: what are the alternative strategies for analysis?
Maria B. Barreto do Carmo; Leticia M. dos Santos; Caroline A. Feitosa; Rosemeire L. Fiaccone; Nívea B. da Silva; Darci N. dos Santos; Maurício L. Barreto; Leila D. Amorim

OBJECTIVE: To analyze the prevalence of common mental disorders (CMD) assessed with the Self Reporting Questionnaire (SRQ-20), using the established cutoff point, and comparing it with the results of a joint correspondence factor analysis (CFA) and cluster analysis and of a latent class analysis (LCA). METHODS: A cross-sectional study was carried out in an urban sample of 1,095 women aged 19 to 55 years. Joint CFA-cluster analysis and LCA were used. RESULTS: We found a high prevalence of CMD, regardless of classification method (37.6% when using the cutoff point; 44.4% and 52% for LCA and joint CFA-cluster, respectively). The alternative analysis strategies describe the cases more efficiently when compared to the traditional cutoff method, especially regarding more severe symptoms. Both alternative strategies also provide a description of the SRQ-20 dimensions in their particularities, which may be useful for the planning and implementation of specific actions in a given population. CONCLUSION: The SRQ-20 cutoff point seems to underestimate the magnitude of CMD among women. The alternative methods of analysis presented herein highlight the different possibilities of using this important instrument of screening for mental health.

Descriptors: Screening; mental health; multivariate analysis; latent class analysis; correspondence analysis

Clinical outcomes of psychotherapy dropouts: does dropping out of psychotherapy necessarily mean failure?
Rodrigo T. Lopes; Miguel M. Gonçalves; Dana Sinai; Paulo P. Machado

OBJECTIVE: A large proportion of psychotherapy patients remain untreated, mostly because they drop out. This study compares the short- and long-term outcomes of patients who dropped out of psychotherapy to those of therapy completers. METHODS: The sample included 63 patients (23 dropouts and 40 completers) from a controlled clinical trial, which compared narrative therapy vs. cognitive-behavioral therapy for major depressive disorder. Patients were assessed at the eighth session, post-treatment, and at 31-month follow-up. RESULTS: Dropouts improved less than completers by the last session attended, but continued to improve significantly more than completers during the follow-up period. Some dropout patients improved with a small dose of therapy (17% achieved a clinically significant change before abandoning treatment), while others only achieved clinically significant change after a longer period (62% at 31-month follow-up). CONCLUSION: These results emphasize the importance of dealing effectively with patients at risk of dropping out of therapy.Patients who dropped out also reported improvement of depressive symptoms without therapy, but took much longer to improve than did patients who completed therapy. This might be attributable to natural remission of depression. Further research should use a larger patient database, ideally gathered by meta-analysis.

Descriptors: Patient dropout; psychotherapy; outcome assessment; unipolar depression

Portuguese and Brazilian guidelines for the treatment of depression: exercise as medicine
Lara F. Carneiro; Maria P. Mota; Felipe Schuch; Andrea Deslandes; José Vasconcelos-Raposo

Depression is a psychiatric disorder and major contributor to the burden of disease worldwide. The strength of evidence of the benefits of exercise as a therapeutic intervention for patients with depression has expanded in the last 30 years. In fact, the available evidence indicates exercise can not only help manage depressive symptoms, but also effect significant improvements in other health outcomes. Clinical guidelines including such recommendations have been issued by different agencies, namely the UK National Institute for Health and Clinical Excellence (NICE), the American Psychiatric Association (APA), and the Royal Australian and New Zealand College of Psychiatrists (rAnZCP). With increasing recognition of the benefits of exercise and shortcomings of healthcare systems, other countries, such as Sweden and Canada, have included exercise in their national guidelines for treating depression. Unfortunately, progress in incorporating exercise guidelines into clinical practice has been slow, and Portugal and Brazil reflect this reality. In this update, we reemphasize the importance of bridging this gap and integrating exercise into clinical practice guidelines as an essential component of depression treatment.

Descriptors: Depression; treatment; exercise; guidelines

Alcohol-related blackouts among college students: Impact of low level of response to alcohol, ethnicity, sex, and environmental characteristics
Priscila D. Gonçalves; Tom L. Smith; Robert M. Anthenelli; George Danko; Marc A. Schuckit

OBJECTIVE: To explore how a genetically-influenced characteristic (the level of response to alcohol [LR]), ethnicity, and sex relate to environmental and attitudinal characteristics (peer drinking [PEER], drinking to cope [COPE], and alcohol expectancies [EXPECT]) regarding future alcohol-related blackouts (ARBs). METHODS: Structural equation models (SEMs) were used to evaluate how baseline variables related to ARB patterns in 462 college students over 55 weeks. Data were extracted from a longitudinal study of heavy drinking and its consequences at a U.S. university. RESULTS: In the SEM analysis, female sex and Asian ethnicity directly predicted future ARBs (beta weights 0.10 and -0.11, respectively), while all other variables had indirect impacts on ARBs through alcohol quantities (beta weights ~0.23 for European American ethnicity and low LR, 0.21 for cannabis use and COPE, and 0.44 for PEER). Alcohol quantities then related to ARBs with beta = 0.44. The SEM explained 23% of the variance. CONCLUSION: These data may be useful in identifying college students who are more likely to experience future ARBs over a 1-year period. They enhance our understanding of whether the relationships of predictors to ARBs are direct or mediated through baseline drinking patterns, information that may be useful in prevention strategies for ARBs.

Descriptors: Alcohol; blackout; college students; peer drinking; drinking to cope; drinking behavior; alcohol drinking in college; binge drinking

Prevalence, clinical correlates and maternal psychopathology of deliberate self-harm in children and early adolescents: results from a large community study
André R. Simioni; Pedro M. Pan; Ary Gadelha; Gisele G. Manfro; Jair J. Mari; Euripedes C. Miguel; Luis A. Rohde; Giovanni A. Salum

OBJECTIVES: Little is known about the prevalence and correlates of deliberate self-harm (DSH) in children from low- and middle-income countries. We investigated the prevalence of DSH and its clinical and maternal psychopathological associations in Brazilian children (n=2,508, ages 6-14y) in a community-based study. METHODS: Participants of the High Risk Cohort Study for the Development of Childhood Psychiatric Disorders (HRC) and their mothers were assessed in structured interviews. Current (last month) and lifetime DSH were estimated, including analysis stratified by age groups. Logistic regressions were performed to investigate the role of the children's clinical diagnoses and maternal psychopathology on DSH prevalence estimates, adjusting for potential confounding factors. RESULTS: The prevalence of current DSH was 0.8% (children 0.6%, adolescents 1%) and lifetime DSH was 1.6% (1.8% and 1.5%, respectively). Current and lifetime DSH were more frequent in children with depression, attention-deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD), even in multiple models accounting for demographic variables and co-occurring psychiatric disorders. Maternal anxiety disorder was strongly associated with current and lifetime DSH in offspring; whereas current DSH, specifically in young children, was associated with maternal mood disorder. CONCLUSION: Diagnoses of depression, ADHD and ODD were consistently associated with DSH, as was having a mother with anxiety disorder.

Descriptors: Deliberate self-harm; self-injurious behavior; suicide attempt; community survey; family health; psychopathology

Schizophrenia and work: aspects related to job acquisition in a follow-up study
Larissa C. Martini; Jair B. Barbosa Neto; Beatriz Petreche; Ana O. Fonseca; Fernanda V. dos Santos; Lílian Magalhães; Alessandra G. Marques; Camila Soares; Quirino Cordeiro; Cecília Attux; Rodrigo A. Bressan

OBJECTIVE: Work is considered one of the main forms of social organization; however, few individuals with schizophrenia find work opportunities. The purpose of this study was to evaluate the relationship between schizophrenia symptoms and job acquisition. METHOD: Fifty-three individuals diagnosed with schizophrenia from an outpatient treatment facility were included in an 18-month follow-up study. After enrollment, they participated in a prevocational training group. At the end of training (baseline) and 18 months later, sociodemographic, clinical data and occupational history were collected. Positive and negative symptoms (Positive and Negative Syndrome Scale - RANSS), depression (Calgary Depression Scale), disease severity (Clinical Global Impression - CGI), functionality (Global Assessment of Functioning - GAF), personal and social performance (Personal and Social Performance - RSR) and cognitive functions (Measurement and Treatment Research to Improve Cognition in Schizophrenia - MATRICS battery) were applied at baseline and at the end of the study. RESULTS: Those with some previous work experience (n=19) presented lower scores on the PANSS, Calgary, GAF, CGI and PSP scales (p < 0.05) than those who did not work. Among those who worked, there was a slight worsening in positive symptoms (positive PANSS). CONCLUSIONS: Individuals with less severe symptoms were more able to find employment. Positive symptom changes do not seem to affect participation at work; however, this calls for discussion about the importance of employment support.

Descriptors: Schizophrenia; work; symptom; support

Effectiveness evaluation of mood disorder treatment algorithms in Brazilian public healthcare patients
Ana F. Lima; Sandro R. Miguel Mírian Cohen; Jacques J. Zimmermann; Flávio M. Shansis; Luciane N. Cruz; Patrícia K. Ziegelmann; Carisi A. Polanczyk; Marcelo P. Fleck

OBJECTIVE: To assess the effectiveness of three mood disorder treatment algorithms in a sample of patients seeking care in the Brazilian public healthcare system. METHODS: A randomized pragmatic trial was conducted with an algorithm developed for treating episodes of major depressive disorder (MDD), bipolar depressive episodes and mixed episodes of bipolar disorder (BD). RESULTS: The sample consisted of 259 subjects diagnosed with BD or MDD (DSM-IV-TR). After the onset of symptoms, the first treatment occurred ~6 years and the use of mood stabilizers began ~12 years. All proposed algorithms were effective, with response rates around 80%. The majority of the subjects took 20 weeks to obtain a therapeutic response. CONCLUSIONS: The algorithms were effective with the medications available through the Brazilian Unified Health System. Because therapeutic response was achieved in most subjects by 20 weeks, a follow-up period longer than 12 weeks may be required to confirm adequate response to treatment. Remission of symptoms is still the main desired outcome. Subjects who achieved remission recovered more rapidly and remained more stable over time. CLINICAL TRIAL REGISTRATION: NCT02901249, NCT02870283, NCT02918097

Descriptors: Mood disorders; bipolar; mood disorders; unipolar; clinical drug studies; economic issues; epidemiology

Analysis of suicide mortality in Brazil: spatial distribution and socioeconomic context
Ana P. Dantas; Ulicélia N. de Azevedo; Aryelly D. Nunes; Ana E. Amador; Marilane V. Marques; Isabelle R. Barbosa

OBJECTIVE: To perform a spatial analysis of suicide mortality and its correlation with socioeconomic indicators in Brazilian municipalities. METHODS: This is an ecological study with Brazilian municipalities as a unit of analysis. Data on deaths from suicide and contextual variables were analyzed. The spatial distribution, intensity and significance of the clusters were analyzed with the global Moran index, MoranMap and local indicators of spatial association (LISA), seeking to identify patterns through geostatistical analysis. RESULTS: A total of 50,664 deaths from suicide were registered in Brazil between 2010 and 2014. The average suicide mortality rate in Brazil was 5.23/100,000 population. The Brazilian municipalities presenting the highest rates were Taipas do Tocantins, state of Tocantins (79.68 deaths per 100,000 population), Itaporã, state of Mato Grosso do Sul (75.15 deaths per 100,000 population), Mampituba, state of Rio Grande do Sul (52.98 deaths per 100,000 population), Paranhos, state of Mato Grosso do Sul (52.41 deaths per 100,000 population), and Monjolos, state of Minas Gerais (52.08 deaths per 100,000 population). Although weak spatial autocorrelation was observed for suicide mortality (I = 0.2608), there was a formation of clusters in the South. In the bivariate spatial and classical analysis, no correlation was observed between suicide mortality and contextual variables. CONCLUSION: Suicide mortality in Brazil presents a weak spatial correlation and low or no spatial relationship with socioeconomic factors.

Descriptors: Suicide; epidemiology; social and political issues; community mental health; statistics

Correlations between caregiver psychiatric symptoms and offspring psychopathology in a low-resource setting
Camila T. Matsuzaka; Milton L. Wainberg; Andrea Norcini Pala; Elis V. Hoffmann; Bruno M. Coimbra; Rosaly F. Braga; Cristiane S. Duarte; Annika C. Sweetland; Marcelo F. Mello

OBJECTIVE: Associations between parental/caregiver depression and adverse child outcomes are well established and have been described through one or more mechanisms: child psychopathology following exposure to a depressed caregiver, child psychopathology exacerbating a caregiver's depression, and caregiver and offspring depression sharing the same etiology. Data from low and middle-income countries is scarce. We examined correlations between common symptoms of mental disorders in caregivers and their offspring's psychopathology in a Brazilian sample. METHODS: In this cross-sectional study, adult caregivers were screened for depression during routine home visits by community health workers as part of the Brazilian Family Health Strategy. Caregivers with suspected depression were assessed using the Zung Self-Rating Depression Scale and the Self-Reporting Questionnaire (SRQ-20). Children's symptoms were evaluated using the Strengths and Difficulties Questionnaire (SDQ). RESULTS: The sample included 68 primary caregivers and 110 children aged 6 to 15 years. Higher caregiver scores on the SRQ-20 correlated significantly with psychiatric symptoms in offspring. CONCLUSION: These results substantiate our hypothesis that child psychopathology correlates with caregivers' psychiatric symptoms. This paper adds to the growing literature on community mental health assessment and can help guide future strategies for reducing the burden of common mental disorders in caregivers and children alike in low and middle-income countries.

Descriptors: Depressive disorder; primary health care; child; caregivers; Brazil

Predictors of length of stay in an acute psychiatric inpatient facility in a general hospital: a prospective study
Fernanda L. Baeza; Neusa S. da Rocha; Marcelo P. Fleck

OBJECTIVE: There have been significant reductions in numbers of psychiatric beds and length of stay (LOS) worldwide, making LOS in psychiatric beds an interesting outcome. The objective of this study was to find factors measurable on admission that would predict LOS in the acute psychiatric setting. METHODS: This was a prospective, observational study. RESULTS: Overall, 385 subjects were included. The median LOS was 25 days. In the final model, six variables explained 14.6% of the variation in LOS: not having own income, psychiatric admissions in the preceding 2 years, high Clinical Global Impression and Brief Psychiatric Rating Scale scores, diagnosis of schizophrenia, and history of attempted suicide. All variables were associated with longer LOS, apart from history of attempted suicide. CONCLUSIONS: Identifying patients who will need to stay longer in psychiatric beds remains a challenge. Improving knowledge about determinants of LOS could lead to improvements in the quality of care in hospital psychiatry.

Descriptors: Outcome studies; inpatient psychiatry; chronic psychiatric illness; administration; other delivery issues

Telomere length and hTERT in mania and subsequent remission
Rugül Köse Çinar

OBJECTIVE: The findings of telomere length (TL) studies in bipolar disorder (BD) are controversial. The aim of the present study was to detect TL, human telomerase reverse transcriptase (hTERT), and brain derived neurotrophic factor (BDNF) in severe mania and subsequent remission. METHODS: Twenty-one medication-free male patients and 20 age and gender matched controls were recruited. The patients were followed in the inpatient clinic, and comparisons were made between the same patients in their remission state and controls. Patients received lithium plus antipsychotics during the follow-up period. Quantitative real-time polymerase chain reaction was performed to verify leukocyte tL and whole blood hTERT gene expression levels. Serum BDNF levels were verified by enzyme-linked immunosorbent assay (ELISA). RESULTS: Compared to controls, manic patients presented shorter telomeres (p < 0.001) whose length increased with treatment (p = 0.001). Patients in the late stages showed shorter TL than those in the early stages and controls (p < 0.001). hTERT gene expression levels were up-regulated in mania and remission compared to controls (p = 0.03 and p = 0.01, respectively). BDNF changes did not reach statistically significant levels. CONCLUSIONS: TL and hTERT gene expression might reflect a novel aspect of BD pathophysiology and TL might represent a novel biomarker for BD staging.

Descriptors: Bipolar disorder; telomere; TERT protein; human

Indirect self-destructiveness in individuals with schizophrenia
Konstantinos Tsirigotis

OBJECTIVE: To explore the indirect self-destructiveness syndrome in patients with schizophrenia.
METHODS: Two hundred individuals with paranoid schizophrenia (117 men and 83 women, mean age 37.15 years), all in remission, were examined using the Polish version of the Chronic Self-Destructiveness Scale. Two hundred well-matched healthy individuals served as a control group.
RESULTS: The intensity of indirect self-destructiveness was greater in the schizophrenia group than in controls. The intensity of each manifestation was as follows (in decreasing order): helplessness and passiveness in the face of difficulties (A5), personal and social neglects (A3), lack of planfulness (A4), poor health maintenance (A2), transgression and risk (A1).
CONCLUSION: Patients with schizophrenia displayed more behaviors that were indirectly self-destructive than healthy controls; they scored better than healthy controls only on caring for their own health. The patients showed the lowest intensity of behaviors connected with the active form of indirect selfdestructiveness, and the highest intensity of behaviors connected with the passive form. These findings may enable delivery of more effective forms of pharmacological and psychosocial help to patients with schizophrenia.

Descriptors: Schizophrenia; indirect self-destructiveness; health maintenance; neglects; planfulness; helplessness

Empathic skills and theory of mind in female adolescents with conduct disorder
Olber E. Arango Tobón; Antonio Olivera-La Rosa; Viviana Restrepo Tamayo; Isabel C. Puerta Lopera

OBJECTIVE: Most studies on conduct disorder (CD) have focused on male adolescents, disregarding analysis of this psychopathology in women. The purpose of this study was to identify differences in empathy and theory of mind (ToM) in a group of adolescent women with CD and a control group.
METHOD: Thirty-six adolescent women were selected from an initial sample of 239 adolescents (CD group = 18, control group = 18). Empathy and ToM were evaluated through objective instruments. Mean comparisons and multivariate analysis were performed to ascertain differences between cases and controls and to propose a prediction model based on clinical status.
RESULTS: Significant differences in empathic abilities and ToM were found between the groups. The model that differentiated both groups was composed of eye-reading ability, perspective taking, and personal distress.
CONCLUSION: These findings are consistent with previous studies. Capacity to take the other's perspective and the recognition of emotions in the face are protective factors against CD in women.

Descriptors: Conduct disorder; empathy; theory of mind; women; callous unemotional traits

Maternal recognition of child mental health problems in two Brazilian cities
Isabel A. Bordin; Bartira M. Curto; Joseph Murray

OBJECTIVE: To identify child behaviors and types of impairment that increase the likelihood of maternal recognition of emotional/behavioral problems (EBP) in children and adolescents.
METHODS: Maternal-reported data were obtained from two subsamples of 11-to-16-year-olds derived from cross-sectional studies conducted in two Brazilian municipalities: Itaboraí, state of Rio de Janeiro (n=480), and Embu, state of São Paulo (n=217). The Itaboraí study involved a representative sample of 6-to-16-year-olds (n=1,248; response rate = 86.0%) selected from the Family Health Program registry, which covered 85.5% of the municipal population. The Embu study was based on a probabilistic sample of clusters of eligible households (women aged 15-49 years, child < 18 years), with one mother-child pair selected randomly per household (n=813; response rate = 82.4%). The outcome variable was mother's opinion of whether her child had EBP. Potential correlates included types of child behaviors (hyperactivity/conduct/emotional problems as isolated or combined conditions) and impairment, assessed using the Strengths and Difficulties Questionnaire (SDQ); child's age and gender; maternal education and anxiety/depression (assessed using the Self-Reporting Questionnaire [SRQ]).
RESULTS: Multivariate regression models identified the following correlates of maternal perception of child EBP: comorbidity (co-occurring hyperactivity/conduct/emotional problems), emotional problems alone, and interference of problems with classroom learning and friendships.
CONCLUSION: Comorbidity of different problem types, emotional problems alone, and interference with classroom learning and friendships increase the likelihood of maternal recognition of EBP in children.

Descriptors: Adolescents; child psychiatry; epidemiology; families; community mental health

Depression and psychodynamic psychotherapy
Ângela Ribeiro; João P. Ribeiro; Orlando von Doellinger

Depression is a complex condition, and its classical biological/psychosocial distinction is fading. Current guidelines are increasingly advocating psychotherapy as a treatment option. Psychodynamic psychotherapy models encompass a heterogeneous group of interventions derived from early psychoanalytic conceptualizations. Growing literature is raising awareness in the scientific community about the importance of these treatment options, as well as their favorable impact on post-treatment outcomes and relapse prevention. Considering the shifting paradigm regarding treatment of depressive disorder, the authors aim to provide a brief overview of the definition and theoretical basis of psychodynamic psychotherapy, as well as evaluate current evidence for its effectiveness.

Descriptors: Depressive disorder; mood disorders, unipolar; psychotherapy; psychoanalysis and psychodynamic therapies

Clinical improvement in patients with borderline personality disorder after treatment with repetitive transcranial magnetic stimulation: preliminary results
Julian Reyes-López; Josefina Ricardo-Garcell; Gabriela Armas-Castañeda; María García-Anaya; Iván Arango-De Montis; Jorge J. González-Olvera; Francisco Pellicer

OBJECTIVE: Current treatment of borderline personality disorder (BPD) consists of psychotherapy and pharmacological interventions. However, the use of repetitive transcranial magnetic stimulation (rTMS) could be beneficial to improve some BPD symptoms. The objective of this study was to evaluate clinical improvement in patients with BPD after application of rTMS over the right or left dorsolateral prefrontal cortex (DLPFC).
METHOD: Twenty-nine patients with BPD from the National Institute of Psychiatry, Mexico, were randomized in two groups to receive 15 sessions of rTMS applied over the right (1 Hz, n=15) or left (5 Hz, n=14) DLPFC. Improvement was measured by the Clinical Global Impression Scale for BPD (CGI-BPD), Borderline Evaluation of Severity Over Time (BEST), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HAM-A), and Barratt Impulsiveness Scale (BIS).
RESULTS: Intragroup comparison showed significant (p < 0.05) reductions in every psychopathologic domain of the CGI-BPD and in the total scores of all scales in both groups.
CONCLUSIONS: Both protocols produced global improvement in severity and symptoms of BPD, particularly in impulsiveness, affective instability, and anger. Further studies are warranted to explore the therapeutic effect of rTMS in BPD.

Descriptors: Borderline personality disorder; neurophysiology; neurosciences; psychosocial factors

Bipolar disorders: is there an influence of seasonality or photoperiod?
Andrea Aguglia; Antonio Borsotti; Giuseppe Maina

OBJECTIVE: To increase understanding of the influence of photoperiod variation in patients with bipolar disorders.
METHODS: We followed a sample of Italian bipolar patients over a period of 24 months, focusing on inpatients. All patients admitted to the Psychiatric Inpatient Unit of San Luigi Gonzaga Hospital in Orbassano (Turin, Italy) between September 1, 2013 and August 31, 2015 were recruited. Sociodemographic and clinical data were collected.
RESULTS: Seven hundred and thirty patients were included. The admission rate for bipolar patients was significantly higher during May, June and July, when there was maximum sunlight exposure, although no seasonal pattern was found. Patients with (hypo)manic episodes were admitted more frequently during the spring and during longer photoperiods than those with major depressive episodes.
CONCLUSIONS: Photoperiod is a key element in bipolar disorder, not only as an environmental factor but also as an important clinical parameter that should be considered during treatment.

Descriptors: Bipolar disorder; seasonality; photoperiod; sunlight

Mood disorder, anxiety, and suicide risk among subjects with alcohol abuse and/or dependence: a population-based study
Carolina D. Wiener; Fernanda P. Moreira; Alethea Zago ;Luciano M. Souza; Jeronimo C. Branco; Jacqueline F. de Oliveira; Ricardo A. da Silva; Luis V. Portela; Diogo R. Lara; Karen Jansen; Jean P. Oses

OBJECTIVE: To evaluate the prevalence of alcohol abuse and/or dependence in a population-based sample of young adults and assess the prevalence of comorbid mood disorders, anxiety, and suicide risk in this population.
METHODS: This cross-sectional, population-based study enrolled 1,953 young adults aged 18-35 years. The CAGE questionnaire was used to screen for alcohol abuse and/or dependence, with CAGE scores ≥ 2 considered positive. Psychiatric disorders were investigated through the structured Mini International Neuropsychiatric Interview (MINI).
RESULTS: Alcohol abuse and/or dependence was identified in 187 (9.60%) individuals (5.10% among women and 15.20% among men). Alcohol abuse and/or dependence were more prevalent among men than women, as well as among those who used tobacco, illicit drugs or presented with anxiety disorder, mood disorder, and suicide risk.
CONCLUSION: These findings suggest that alcohol abuse and/or dependence are consistently associated with a higher prevalence of psychiatric comorbidities, could be considered important predictors of other psychiatric disorders, and deserve greater public heath attention, pointing to the need for alcohol abuse prevention programs.

Descriptors: Alcohol abuse and/or dependence; anxiety; mood disorder; depression; suicide risk

Further evidence of psychological factors underlying choice of elective cesarean delivery (ECD) by primigravidae
Nasrin Matinnia; Mohammad Haghighi; Leila Jahangard; Faisal B. Ibrahim; Hejar A. Rahman; Ali Ghaleiha; Edith Holsboer-Trachsler; Serge Brand

OBJECTIVE: Requests for elective cesarean delivery (ECD) have increased in Iran. While some sociodemographic and fear-related factors have been linked with this choice, psychological factors such as self-esteem, stress, and health beliefs are under-researched.
METHODS: A total of 342 primigravidae (mean age = 25 years) completed questionnaires covering psychological dimensions such as self-esteem, perceived stress, marital relationship quality, perceived social support, and relevant health-related beliefs.
RESULTS: Of the sample, 214 (62.6%) chose to undergo ECD rather than vaginal delivery (VD). This choice was associated with lower self-esteem, greater perceived stress, belief in higher susceptibility to problematic birth and barriers to an easy birth, along with lower perceived severity of ECD, fewer perceived benefits from VD, lower self-efficacy and a lower feeling of preparedness. No differences were found for marital relationship quality or perceived social support.
CONCLUSIONS: The pattern suggests that various psychological factors such as self-esteem, self-efficacy, and perceived stress underpin the decision by primigravidae to have an ECD.

Descriptors: Elective cesarean delivery; vaginal delivery; psychological predictors; Health Belief Model; fear; stress