Religiosidade, espiritualidade, desfechos clínicos e marcadores biológicos na depressão

A depressão representa um transtorno mental de grande prevalência e impacto para saúde pública. Pacientes com quadros depressivos em atendimento terciário apresentam em geral quadros com sintomatologia mais grave, com maior recorrência, menor chance de remissão dos sintomas e maior risco de suicídio. Sendo assim, o entendimento de fatores capazes de melhorar o prognóstico e tratamentos, em especial nos pacientes com maior gravidade e riscos, constitui importante questão de pesquisa para psiquiatria e saúde mental. A religiosidade e espiritualidade (R/E), por sua vez, têm sido consideradas como importantes fatores na avaliação e tratamento de pacientes com depressão. No Brasil, por exemplo, boa parte dos pacientes consideram a religiosidade como algo muito importante em suas vidas e muitos pacientes desejam abordar tais fatores em seus atendimentos de saúde. Evidências científicas reforçam que em geral pacientes com maior R/E possuem menor risco de suicídio, maior recuperação de sintomas depressivos e menor incidência de depressão em estudos prospectivos. Por outro lado, o entendimento dos mecanismos através dos quais a R/E exerce seus efeitos sobre desfechos clínicos na depressão segue como relevante fator a ser compreendido pela pesquisa em saúde mental. O objetivo da presente tese é avaliar em pacientes com depressão atendidos na internação e ambulatório do Hospital de Clínicas de Porto Alegre a relevância e impacto da R/E na depressão sobre diferentes perspectivas: (1) avaliação da percepção e importância do tema pelos pacientes; (2) entendimento das relações entre diversas dimensões da R/E, fatores positivos (e.g. resiliência, suporte social) e sintomas depressivos; (3) impacto da R/E no risco de suicídio e remissão de sintomas depressivos em 6 meses de tratamento; e (4) correlação da R/E com marcadores biológicos em pacientes com depressão internados. Os resultados apresentados nos estudos demonstram que a maior parte dos pacientes apresenta interesse sobre religiosidade e espiritualidade (82,1%), embora a maioria (63,1%) nunca tenha sido questionados em seus atendimentos de saúde sobre o tema. Além do mais, 68.3% dos pacientes gostariam de participar em uma psicoterapia integrada a espiritualidade no seu tratamento para depressão. Fatores positivos como resiliência, propósito, esperança, fé, foram identificados como possíveis mediadores de efeitos positivos da R/E em análise de rede de pacientes com depressão. Em seguimento prospectivo de 6 meses, uma maior frequência a encontros religiosos (DUREL) foi relacionado a chances 80% maiores de remissão de sintomas depressivos (OR 1.83, P=0.02). Diversas dimensões da R/E, por sua vez, como religiosidade intrínseca (DUREL) (t-statistic - 2.421, P=0.01), frequência a encontros religiosos (DUREL) (t-statistic -2.172, P=0.03) e escore total de qualidade de vida ligada a religiosidade, espiritualidade e crenças pessoais (WHOQOL-SRPB) (t-statistic -3.670, P=0.00) demonstraram correlações negativas com risco 10 de suicídio. Ademais, em pacientes com depressão internados, efeitos positivos e protetores da religiosidade intrínseca foram correlacionados a maiores níveis do fator neurotrófico derivado do cérebro (BDNF, brain-derived neurotrophic factor) na alta hospitalar, possível marcador de neuroplasticidade cerebral e mediador dos efeitos da R/E sobre depressão. Os resultados apresentados reforçam a relevância do estudo da R/E na psiquiatria, apresentam possíveis mediadores de efeito da R/E sobre a depressão e salientam a importância clínica de sua abordagem em pacientes com sintomatologia grave de depressão.Depression represents a common disorder with a relevant impact on public health. Depressed patients in specialized tertiary care, usually present worse clinical outcomes, including higher recurrence of depressive episodes, lower remission rates, and higher suicide risk, compared to community depressed patients. Considering that, understanding factors capable to improve treatment and prognosis, especially for those patients with worse symptomatology, certainly represents a key issue to psychiatry and mental health research. Religiosity and spirituality, otherwise, are increasingly recognized as relevant aspects to be addressed among depressed patients. In Brazil, particularly, most individuals consider religiosity and spirituality (R/S) a very important aspect of their lives, and most patients would like to address those issues in their health consultations. Empirical evidence, reinforces that, generally, patients with more R/S present lower suicide risk, higher improvement of depressive symptoms and lower incidence of depressive episodes in prospective studies. Nevertheless, undertanding the pathways toward which R/S exert their effects in depression remains a key issue to mental health research. The present thesis aimed to evaluate in samples of tertiary care depressed patients at psychiatric inpatient unit and outpatient mood disorder clinic, the role of R/S over depressive disorder from different perspectives: (1) perception of relevance and patients interest in R/S issues; (2) evaluate the complex interplay between different R/S domains, positive mental health factors (e.g. resilience, social support) and depressive symptoms; (3) the impact of R/S over suicide risk and 6-month prospective remission rates of depressive symptoms; and (4) the relationship between R/S and biological markers of depressive disorders among depressive inpatients. Our findings showed that most patients identify that R/S represent a significant aspect of their health care (82.1%), but most of them were never asked about those topics in health care consultations (63.1%). Furthermore, 68.3% of patients demonstrate interest in spiritually integrated psychotherapy in their treatment of depression. Positive health factors such as resilience, hope, purpose, faith, but not social support, were identified as potential pathways across R/S and better outcomes of depressive symptoms in a network analysis. In a 6-month prospective follow-up, religious attendance (DUREL) was identified as a key predictor of remission of depressive symptoms, with 80% higher odds of remission in the follow-up in patients with higher religious attendance (OR 1.83, P=0.02). Different R/S domains, including religious attendance (DUREL) (t-statistic -2.172, P=0.03), intrinsic religiosity (DUREL) (t-statistic -2.421, P=0.01) and religiousness, spirituality and personal beliefs quality of life (WHOQOL-SRPB) (t-statistic -3.670, P=0.00), were inversely related to 12 suicide risk. Moreover, in a sample of depressive inpatients, higher intrinsic religiosity was correlated to higher BDNF serum levels at discharge, a potential biological marker of recovery and neuroplasticity in depressed patients. The present findings reinforce the relevance of R/S and psychiatric research and the importance to address those issues in clinical practice. The findings also revealed potential mechanisms or pathways to understand the benefits of R/S over depression, especially among those patients with more severe depressive symptoms and higher risks

Increased levels of brain-derived neurotrophic factor are associated with high intrinsic religiosity among depressed inpatients

Recognition of the importance of religion and spirituality in psychiatry is increasing, and several studies have shown a predominantly inverse relationship between religiosity and depression. Brain-derived neurotrophic factor (BDNF) is a widely studied brain neurotrophin responsible for synaptic plasticity, dendritic and neuronal fiber growth, and neuronal survival. The objective of the present study was to evaluate BDNF levels across high and low intrinsic religiosity (IR) in depressed inpatients. Serum BDNF levels were evaluated from 101 depressed inpatients at hospital admission and 91 inpatients at discharge. Religiosity was assessed using a validated version of the Duke University Religion Index. High IR patients had significantly higher serum BDNF at discharge than do low IR (52.0 vs. 41.3 ng/mL, P = 0.02), with a Cohen’s d effect size difference of 0.56. High IR patients had a statistically significant increase in BDNF levels from admission to discharge (43.6 ± 22.4 vs. 53.8 ± 20.6 ng/mL, −1.950 (paired t-statistic), P = 0.05). The relationship between IR and BDNF levels (F = 6.199, P = 0.00) was controlled for the effects of depressive symptoms (β = 2.73, P = 0.00) and psychiatric treatments, including selective serotonin reuptake inhibitors (SSRIs) (β = 0.17, P = 0.08), serotonin and norepinephrine reuptake inhibitors (SNRIs) (β = −0.23, P = 0.02), tricyclic antidepressants (TCAs) (β = −0.17, P = 0.10), lithium (β = 0.29, P = 0.00), anticonvulsants (β = 0.22, P = 0.03), antipsychotics (β = −0.05, P = 0.61), and electroconvulsive therapy (β = 0.00, P = 0.98). The current findings suggest a potential pathway to help understand the protective effect of religiosity in depressive disorders

Factors associated with adherence to sports and exercise among outpatients with major depressive disorder

Introduction: Individuals with major depressive disorder (MDD) face more barriers to engagement in sports and exercise interventions. Evaluating clinical and demographic factors associated with adherence to sports and exercise among MDD outpatients could support development of new options and strategies to increase their participation. Methods: In a cross-sectional study, 268 depressed outpatients were evaluated (83.51% females; mean age = 50.74 [standard deviation {SD} = 10.39]). Sports and exercise participation were assessed using a question about participation frequency during the previous month. Clinical and demographic factors were evaluated. Linear regression was used to identify predictors of participation in sports and exercise. Results: MDD patients with mild symptoms of depression (odds ratio [OR] = 2.42; 95% confidence interval [95%CI] 1.00, 5.88; p = 0.04) and patients with mild to moderate symptoms (OR = 3.96; 95%CI 1.41, 11.15; p = 0.009) were more likely to engage regularly in sports and exercise than patients with more severe depression. Moreover, smoking (OR = 0.23; 95%CI 0.67, 0.80; p = 0.007) and being divorced (OR = 0.22; 95%CI 0.57, 0.86; p = 0.03) were associated with lower rates of engagement in sports and exercise. Conclusion: Our findings indicate a significant association between clinical and demographic factors and participation in sports and exercise among MDD outpatients

Interpersonal psychotherapy as add-on for treatment-resistant depression : a pragmatic randomized controlled trial

Background Treatment-resistant depression (TRD) is an extremely prevalent clinical condition. Although Interpersonal Psychotherapy (IPT) is an established treatment for uncomplicated depression, its effectiveness has never before been studied in patients with TRD in real-world settings. We investigate IPT as an adjunct strategy to treatment as usual (TAU) for TRD patients in a pragmatic, randomized, controlled trial. Methods A total of 40 adult patients with TRD (satisfying the criteria for major depressive disorder despite adequate antidepressant treatment) were recruited from a tertiary care facility for this pragmatic trial and blinded to the evaluator. Patients were randomized to one of two treatment conditions: (1) TAU – pharmacotherapy freely chosen by the clinician (n=23) and (2) TAU+IPT (n=17). Assessments were performed at weeks 8, 12, 19 and 24. Changes in the estimated means of the Hamilton Depression Rating Scale score were the primary outcome measure. Secondary outcomes included patient-rated scales and quality of life scales. We used a linear mixed model to compare changes over time between the two groups. Results Both treatments lead to improvements in depressive symptoms from baseline to week 24 with no significant between group differences in either primary: TAU (mean difference: 4.57; CI95%: 0.59–8.55; d=0.73) vs. IPT+TAU (mean difference: 5.86, CI95%: 1.50–10.22; d=0.93) or secondary outcomes. Limitations Our relatively small sample limits our ability to detect differences between treatments. Conclusions Both treatments lead to equal improvements in depressive symptoms. We found no evidence to support adding IPT to pharmacotherapy in patients with TRD

Implementation of Group Interpersonal Psychotherapy in primary care

OBJECTIVE To show the implementation process of IPT-G in primary care, including facilitating and obstructing factors, implementation strategies, and training and supervision of primary care professionals. METHODS Quantitative (cross-sectional and longitudinal) analysis of pre and post-knowledge tests; qualitative analyses of the training courses; patient recruitment; conduction of IPT-G sessions; supervision of IPT-G therapists; application of a semi-structured questionnaire to assess, investigate, and develop strategies against the identified barriers. RESULTS About 120 clinicians answered the pre-test; 84 completed the post-test. Pre- and post-test scores of IPT-G knowledge were significantly different. Twenty initially trained clinicians completed additional supervision in IPT-G. Qualitative analysis identified twelve barriers and six facilitators to IPT-G implementation in individual, organizational, and systemic contexts. CONCLUSIONS Implementation of IPT-G in primary care is a complex process with several steps. In the first step, health professionals were successfully trained in IPT-G. However, subsequent steps were more complex. Therefore, careful planning of IPT-G implementation is essential to maximize the success of this innovation

Sydney Melancholia Prototype Index (SMPI) : translation and cross-cultural adaptation to Brazilian Portuguese

Introduction: Depression is possibly not a single syndrome but rather comprises several subtypes. DSM-5 proposes a melancholia specifier with phenotypic characteristics that could be associated with clinical progression, biological markers or therapeutic response. The Sydney Melancholia Prototype Index (SMPI) is a prototypic scale aimed to improve the diagnosis of melancholia. So far, there is only an English version of the instrument available. The aim of this study is to describe the translation and adaptation of the English version of the SMPI into Brazilian Portuguese. Methods: Translation and cross-cultural adaptation of the self-report (SMPI-SR) and clinician-rated (SMPICR) versions into Brazilian Portuguese were done following recommendations of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). This guideline includes the following steps: preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, debriefing results review, proofreading and final report. Results: The Brazilian Portuguese versions of the SMPI were well-accepted by respondents. Changes in about two-thirds of the items were considered necessary to obtain the final Brazilian Portuguese version of the SMPI. Conclusions: Both versions of the SMPI are now available in Brazilian Portuguese. The instrument could become an important option to enhance studies on melancholia in Portuguese-speaking samples

First-time administration of the Sydney Melancholia Prototype Index (SMPI) to non-English-speaking patients : a study from Brazil

Objective: The Sydney Melancholia Prototype Index (SMPI) is a scale that uses a non-conventional strategy to assess melancholia status based on prototypic symptoms and illness course variables. This study aimed to evaluate the performance of the first translation of this instrument in a non-Englishspeaking population. Methods: A sample comprising 106 Brazilian outpatients with depression was evaluated simultaneously with the Brazilian version of the self-rated SMPI (SMPI-SR) and clinician-rated SMPI (SMPICR). The kappa coefficient and t test were used to evaluate concurrent validity vs. DSM-IV, CORE system, Hamilton Depression Rating Scale-6 item (HAM-D6), and HAM-D17 assignments to a melancholic or non-melancholic class. The prevalence of melancholia as well as sensitivity and specificity were calculated across instruments. Results: The prevalence of melancholia was highest using DSM-IV criteria (56.6%). The kappa agreement between SMPI-CR and DSM-IV melancholia assignment was moderate (kappa 0.44, p <= 0.001). SMPI-CR-assigned melancholic patients had significantly higher CORE, HAM-D17, and HAM-D6 scores. The test-retest consistency values for the SMPI were modest at best, and somewhat superior for the CR version. Conclusion: The Brazilian SMPI-CR presented satisfactory psychometric properties (which were superior to those of the SMPI-SR), and therefore appears to be a useful option for identifying melancholia and studying its causes and optimal treatments