An educational training program for physicians for diagnosis and treatment of depression

OBJECTIVE: The American Regional Office of the WHO has launched a major initiative to reduce the prevalence of affective disorders region-wide that includes focusing on the primary health care system. This study evaluated the results of an educational training program for Brazilian primary care physicians that measured changes in knowledge, attitudes, and practice. METHODS: A total of 17 primary care physicians and 1,224 patients participated in the study. Physician's knowledge, attitudes, and clinical practice were assessed one-month prior and one-month following the training program. In addition, the patients that visited the clinic during a typical week completed depression symptom self-ratings, including the Zung and a DSM-IV/ICD-10 major depression checklist at both times. RESULTS: The training program showed limited benefits in this small sample of physicians. The program was unable to demonstrate benefit in improving knowledge about depression and in changing disorder-related attitudes. There were no changes in the diagnostic rates of major depression. There was some evidence to support improvement in psychopharmacological management. The physicians seemed more confident in treating patients, as there was a reduction of referrals to the specialists. Lack of statistical power prevented the latter two findings from reaching statistical significance. CONCLUSIONS: The inclusion of primary care physicians is a central component of any initiative to reduce the treatment gap and lag of depression. However, more effective methods of training Brazilian primary care physicians in the management of major depression need to be tested.OBJETIVO: Avaliar os resultados da aplicação de programa de treinamento da Organização Mundial de Saúde, voltado para diagnóstico e tratamento da depressão, dirigido a médicos clínicos gerais. MÉTODOS: Dezessete clínicos e 1.224 pacientes da cidade de Campinas, SP, participaram do estudo. Um mês antes e um após o treinamento, foram avaliados o conhecimento dos médicos, suas atitudes e o atendimento prestado aos pacientes; esses, por sua vez, completaram escalas de auto-avaliação de sintomas depressivos: Zung e um checklist para depressão maior do manual para diagnóstico e estatística em saúde mental (DSM-IV/CID-10). A mudança de conhecimento e atitude dos clínicos entre as fases 1 e 2 foi avaliada pelos testes t de Student. Mudanças com relação ao conhecimento de cada indivíduo foram mensuradas pelo teste de qui-quadrado de McNemar. As diferenças entre o modo de atender os pacientes entre as duas fases foram determinadas pelo teste de qui-quadrado de Pearson. A concordância diagnóstica foi analisada utilizando o Kappa, com o intuito de corrigir a concordância ao acaso. RESULTADOS: O programa mostrou benefícios limitados nessa amostra de clínicos gerais. Não foi capaz de mostrar aumento do conhecimento sobre a depressão e nem quanto à atitude dos médicos com relação a esse transtorno. Não houve modificação no número de casos diagnosticados antes ou após o programa. Existiram algumas evidências com relação à melhora no manejo psicofarmacológico. Aparentemente, o programa tornou os clínicos mais confiantes para o tratamento da depressão, diminuindo o número de encaminhamentos feitos aos profissionais da área de saúde mental. Porém, um baixo poder estatístico não permitiu que os dois últimos achados atingissem significância. CONCLUSÕES: A inclusão de clínicos gerais é um componente central de qualquer iniciativa para melhorar a detecção e o tratamento da depressão, porém faz-se necessário testar melhores métodos de treinamento dos clínicos brasileiros no manejo desta.Serviço de Saúde 'Dr. Cândido Ferreira'Ministério da SaúdeBrown University Providence Department of Psychiatry and Human BehaviorOrganização Mundial da Saúde Organização Panamericana de SaúdeUniversidade Federal de São Paulo (UNIFESP)UNIFESP, Departamento de PsiquiatriaSciEL

Aripiprazol no tratamento do transtorno de estresse pós-traumático: um ensaio clínico aberto

OBJECTIVE: Post traumatic stress disorder is frequent in the general population (7.8%-lifetime-USA). The selective serotonin reuptake inhibitors are the first choice of treatment but result in low remission rates. This study aims to evaluate the effect of aripiprazole monotherapy for the treatment of post traumatic stress disorder. METHOD: Thirty-two patients diagnosed with post traumatic stress disorder were included in a 16-week open label trial of aripiprazole. They were evaluated at baseline, week 8, and 16 with the Clinician-Administered PTSD Scale, Beck Depression Inventory, Beck Anxiety Inventory, Medical Outcome Study Short Form 36, and Social Adjustment Scale. Statistical analysis were performed with an intention-to-treat approach and last observation carried forward. A general linear model for repeated measures comparing the factor with 3 continuous measures from baseline, 8 and 16 weeks was used. A between-subject factor was included RESULTS: Nine patients discontinued the treatment. The mean aripiprazole dose was 9.6 (± 4.3) mg/day. The mean scores at baseline and endpoint for all measures were: Clinician-Administered PTSD Scale - 82.7 (± 23.1) and 51.4 (± 31.4) (F = 11.247, p = 0.001); Beck Anxiety Inventory - 31.7 (± 13.4) and 25.4 (± 18.2) (F = 8.931, p = 0.011); Social Adjustment Scale - 2.4 (± 0.45) and 2.27 (± 0.57) (F = 8.633, p = 0.012); Medical Outcome Study Short Form 36 - 76.6 (± 14.11) and 94.01 (± 25.06) (F = 10.127 p = 0.007); and Beck Depression Inventory - 26.06 (± 11.6) and 21.35 (± 12.6) (F = 1.580, p = 0.042). In all measurements, the differences were statistically significant. CONCLUSIONS: Patients achieved a good response to treatment with aripiprazole, but placebo-controlled studies are needed for more accurate results.OBJETIVO: O transtorno de estresse pós-traumático é um quadro prevalente (7,8%-lifetime-EUA) que provoca grande prejuízo aos pacientes. Os inibidores seletivos de recaptação de serotonina, medicação de primeira escolha para o tratamento, mostram baixos índices de remissão. Este estudo pretende apresentar uma diferente escolha de medicamento para tratar o transtorno de estresse pós-traumático. MÉTODO: Trinta e dois pacientes com transtorno de estresse pós-traumático receberam aripiprazol por 16 semanas. Foram submetidos na entrada, 8 e 16 semanas às escalas Clinician-Administered PTSD Scale, Beck Depression Inventory, Beck Anxiety Inventory, Medical Outcome Study Short Form 36 e Social Adjustment Scale. Foi usado o modelo linear generalizado para medidas repetidas comparando o fator com as três medidas contínuas nos três pontos de avaliação. Foi feita uma comparação entre sujeitos (grupo tratamento) usando modelo linear generalizado univariado. Usamos a intenção de tratamento e a estratégia da última observação com endpoint (Last Observation Carried Forward). RESULTADOS: Nove pacientes descontinuaram antes da segunda avaliação. A dose média foi 9,6 (± 4,3) mg/dia. As medidas na entrada e no final do tratamento foram: Clinician-Administered PTSD Scale - 82,7 (± 23,1) e 51,4 (± 31,4) (F = 11,247, p = 0,001); Beck Anxiety Inventory - 31,7 (± 13,4) e 25,4 (± 18,2) (F = 8,931, p = 0,011); Social Adjustment Scale - 2,4 (± 0,45) e 2,27 (± 0,57) (F = 8,633, p = 0,012); Medical Outcome Study Short Form 36 - 76,6 (± 14,11) e 94,01 (± 25,06) (F = 10,127 p = 0,007); e Beck Depression Inventory - 26,06 (± 11,6) e 21,35 (± 12,6) (F = 1,580, p = 0,042). Em todas as medidas, as diferenças foram estatisticamente significativas. CONCLUSÕES: O aripiprazol alcançou uma boa resposta em pacientes com transtorno de estresse pós-traumático, mas para resultados mais acurados ainda são necessários estudos controlados com placebo.Universidade Federal de São Paulo (UNIFESP) Department of Psychiatry Victims of Violence and Stress ProgramUNIFESP, Department of Psychiatry Victims of Violence and Stress ProgramSciEL

Behavioral indicators of propensity to murder sex offenders

OBJECTIVE: We evaluated the association between personality characteristics and type of rape (with or without the victim's death). METHODS: As a strategy to study, we used behavioral indicators that may be associated with antisocial personality in order to differentiate the externalizing behaviors of sex offenders who kill its victims. RESULTS: The sex offenders had externalizing behaviors related to antisocial personality. The group of individuals who committed rape resulting in death has these behavioral traits more prevalent later in life. CONCLUSION: We conclude that sex offenders, appear to have indicators that allow a deeper investigation in relation to antisocial personality, but those who kill their victims differ in their historical behavior of those who do not commit murder subsequent to the act of rape. Are indicators of behavioral propensity to murder sex offenders, are more commonly under the influence of alcohol/drugs during the act of rape, suicidality, premature start of criminal life and high impulsivity.OBJETIVO: Avaliamos se existe associação entre características de personalidade e tipo de estupro cometido (com ou sem a morte da vítima). MÉTODOS: Como estratégias de estudo, utilizaram-se indicadores comportamentais que podem ser associados à personalidade antissocial, de modo a diferenciar os comportamentos externalizantes de agressores sexuais que matam ou não suas vítimas. RESULTADOS: Os agressores sexuais apresentaram comportamentos externalizantes relacionados à personalidade antissocial. O grupo de indivíduos que cometeu estupro seguido de morte tem esses traços comportamentais mais presentes no decorrer da vida. CONCLUSÃO: Concluímos que os agressores sexuais aparentam ter indicadores que permitem uma investigação mais profunda em relação à personalidade antissocial, mas aqueles que matam suas vítimas diferem quanto ao seu histórico comportamental daqueles que não cometem o homicídio subsequente ao ato de estupro. São indicadores comportamentais da propensão ao homicídio em agressores sexuais: estarem, mais comumente, sob os efeitos de álcool/drogas durante o ato de estupro, propensão ao suicídio, prematuridade de início da vida criminosa e alta impulsividade

The joint structure of major depression, anxiety disorders, and trait negative affect

Background: Dimensional models of psychopathology demonstrate that two correlated factors of fear and distress account for the covariation among depressive and anxiety disorders. Nevertheless, these models tend to exclude variables relevant to psychopathology, such as temperament traits. This study examined the joint structure of DSM-IV-based major depression and anxiety disorders along with trait negative affect in a representative sample of adult individuals residing in the cities of São Paulo and Rio de Janeiro, Brazil. Methods: The sample consisted of 3,728 individuals who were administered sections D (phobic, anxiety and panic disorders) and E (depressive disorders) of the Composite International Diagnostic Interview (CIDI) 2.1 and a validated version of the Positive and Negative Affect Schedule. Data were analyzed using correlational and structural equation modeling. Results: Lifetime prevalence ranged from 2.4% for panic disorder to 23.2% for major depression. Most target variables were moderately correlated. A two-factor model specifying correlated fear and distress factors was retained and confirmed for models including only diagnostic variables and diagnostic variables along with trait negative affect. Conclusions: This study provides support for characterization of internalizing psychopathology and trait negative affect in terms of correlated dimensions of distress and fear. These results have potential implications for psychiatric taxonomy and for understanding the relationship between temperament and psychopathology

Structural Validity of the Tonic Immobility Scale in a Population Exposed to Trauma: Evidence from Two Large Brazilian Samples

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