Univ Fed Sao Paulo UNIFESP, Dept Psiquiatria, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Programa Posgrad Psiquiatria & Psicol Med, Sao Paulo, SP, BrazilUniv Fed Sao Paulo UNIFESP, Dept Psiquiatria, Sao Paulo, SP, BrazilUniv Fed Sao Paulo, Programa Posgrad Psiquiatria & Psicol Med, Sao Paulo, SP, BrazilWeb of Scienc

Brietzke, Elisa

Leclerc, Emilie

Mari, Jair de Jesus

Ugarte Bustamante

Brazilian Journal of Psychiatry

English

Ugarte Bustamante [UNIFESP], Lineth Hiordana [UNIFESP]

Leclerc, Emilie [UNIFESP]

Mari, Jair de Jesus [UNIFESP]

Brietzke, Elisa [UNIFESP]

Repositório Institucional UNIFESP

same span prompted interruption of the task. Reliabilitywas estimated by the split-half method, using the firsttrials from each span to compose the first half and thesecond trials to compose the second half. Reliable changeindexes (RCIs) were calculated for all test measures.Table 1 shows descriptive data, internal consistency,and reliable change coefficients for each task. Reliabilitywas high for Digit Span forward, low for Digit Spanbackward, and moderate for the Corsi Block-Tappingtask. The RCI for the tasks can be used to tracksignificant changes in longitudinal assessment, althoughthe high variability and moderate reliability of the tasks arelikely to hinder assessment of mild or slight changes.Jonas J. de Paula,1,2 Leandro F. Malloy-Diniz,1,3Marco A. Romano-Silva1,31Instituto Nacional de Cieˆncia e Tecnologia em Medicina Molecular(INCT-MM), Faculdade de Medicina, Universidade Federal de MinasGerais (UFMG), Belo Horizonte, MG, Brazil. 2Departamento dePsicologia, Faculdade de Cieˆncias Me´dicas de Minas Gerais, BeloHorizonte, MG, Brazil. 3Departamento de Sau´de Mental, Faculdadede Medicina, UFMG, Belo Horizonte, MG, Brazil.Submitted Dec 03 2015, accepted Dec 13 2015.AcknowledgementsThis work was supported by the following grants: APQ-01972/12-10, APQ-02755-10, APQ-04706-10, and CBB-APQ-00075-09 from Fundac¸a˜o de Amparo e` Pesquisa doEstado de Minas Gerais (FAPEMIG); 573646/2008-2from Conselho Nacional de Desenvolvimento Cientı´fico eTecnolo´gico (CNPq).DisclosureThe authors report no conflicts of interest.References1 Baddeley A. Working memory: theories, models, and controversies.Annu Rev Psychol. 2012;63:1-29.2 Kessels RP, van den Berg E, Ruis C, Brands AM. The backward spanof the Corsi Block-Tapping Task and its association with the WAIS-IIIDigit Span. Assessment. 2008;15:426-34.3 Jacobson NS, Truax P. Clinical significance: a statistical approach todefining meaningful change in psychotherapy research. J ConsultClin Psychol. 1991;59:12-9.4 Foss MP, Carvalho VA, Machado TH, Reis GC, Tumas V, CaramelliP, et al. Mattis dementia rating scale (DRS) normative data for theBrazilian middle-age and elderly populations. Dement Neuropsychol.2013;7:374-9.5 Assis Lde O, de Paula JJ, Assis MG, de Moraes EN, Malloy-Diniz LF.Psychometric properties of the Brazilian version of Pfeffer’s Func-tional Activities Questionnaire. Front Aging Neurosci. 2014;6:255.It is time to prepare mentalhealth services to attend tomigrants and refugeesRev. Bras. Psiquiatr. 2016;38:263-264doi:10.1590/1516-4446-2015-1883Brazil is a multicultural nation. Since the 1970s, the coun-try has received a substantial number of immigrants andrefugees, mainly from Latin America, Europe, Africa, andChina. In 2012, over 940,000 people were living in Brazilwith a permanent visa.1 Compared to other countries,this still represents a small percentage of the popula-tion (0.9%), but with recent international events, rapidgrowth is expected. As of March 2015, according to theBrazilian Federal Police, 1,189,947 immigrants with apermanent visa and 4,842 refugees were living in thecountry.2The immigration process represents a risk factor formental health problems, putatively through several path-ways including unfavorable life circumstances (such aswars, extreme poverty, and political persecution); expo-sure to stress; low income; loss of contact with family;losses in social status, culture, and home; and lack ofcontact with one’s ethnic and cultural group of origin. Thefragility of migrant populations has also been linked tomarginalization, legal issues, lack of social support, andeveryday exposure to stigma and discrimination.3Furthermore, immigration implies acculturation and con-tinuous adaptation to a new language, different culturalroles, and an unknown and frequently hostile environ-ment, requiring constant effort to survive and succeed.4Although the impact of a migration experience on thevulnerability to mental disorders and emotional sufferingis relatively well described, mental health services inBrazil are still poorly adapted to the needs of immigrantsand refugees, and health professionals are largely cul-turally unprepared to establish good rapport with thesepatients. One study on Bolivian immigrants in the cityof Sa˜o Paulo found that 72% of the sample reportedexperiences of discrimination during medical appoint-ments in the public health system.5In addition, although the number of immigrants andrefugees who seek mental health care in Brazil is growing,there are international data supporting that most mentalhealth resources are underused by this population.6 Thiscan be attributed to several barriers to care, includingsociocultural differences (in manifestations of symptoms,in expression of emotional suffering and attribution ofcauses, and in methods used to manage mental healthRev Bras Psiquiatr. 2016;38(3)Letters to the Editors 263problems) and stigma. For example, some cultures withstrong family bonds can perceive mental disorders assomething that would expose the family and affect itsreputation. Structural-contextual barriers in Brazil includethe lack of access to appropriate and culturally sensi-tive mental health services, due to the lack of staffmembers who understand and speak languages otherthan Portuguese, and the very small number of workersfrom minority groups or trained to work with people fromdifferent ethnic and cultural backgrounds. Brazil’s politicaland racial context could also affect the capacity of adultsand children to trust the mental health system to helpthem, especially among undocumented immigrants.These barriers are even more complex in small munici-palities and far from major centers.Reducing barriers to care and providing culturally appro-priate mental health services is a significant challengefor professionals, policy makers, and migrant and refugeeadvocacy organizations. To cultivate best practices inassessment and diagnosis, clinicians could take varioussteps to examine consciously and take into considera-tion the extension of cultural and linguistic differencesbetween patients and the predominant culture of Brazil.One way to do this is to recognize the dynamic nature ofculture and incorporate cultural variables at all stages ofthe assessment process, e.g., by using culturally sensi-tive interviews or collecting data on acculturation, reli-gious practices, racism/discrimination, and cultural values.The use of a contextual approach that takes the explanatorymodels of patients into account, and whereby patientscould understand the medical hypothesis easily, wouldalso be useful, as would assessment of the possibilityof culture-related syndromes. Finally, for mental healthprofessionals to have access to translators and work inpartnership with the different cultural communities wouldgreatly benefit the health services and help meet theneeds of the growing number of immigrants and refugeesin Brazil.Lineth Hiordana Ugarte Bustamante,1,2 Emilie Leclerc,1,2Jair de Jesus Mari,1,2 Elisa Brietzke1,21Departamento de Psiquiatria, Universidade Federal de Sa˜o Paulo(UNIFESP), Sa˜o Paulo, SP, Brazil. 2Programa de Po´s-Graduac¸a˜oem Psiquiatria e Psicologia Me´dica, UNIFESP, Sa˜o Paulo, SP,BrazilSubmitted Dec 07 2015, accepted Dec 18 2015.DisclosureThe authors report no conflicts of interest.References1 Instituto Brasileiro de Geografia e Estatı´stica (IBGE). Vamos conhecero Brasil / nosso povo / migrac¸a˜o e deslocamento [Internet]. [cited 2016Jan 29]. 7a12.ibge.gov.br/vamos-conhecer-o-brasil/nosso-povo/migracao-e-deslocamento.2 Arantes JT. O panorama da imigrac¸a˜o no Brasil [Internet]. 2015 Jul 07[cited 2015 Sep 23]. exame.abril.com.br/brasil/noticias/o-panorama-da-imigracao-no-brasil.3 Coutinho MPL, Rodrigues IF, Ramos N. Transtornos mentais comunsno contexto migrato´rio internacional. Psico. 2012;43:400-7.4 Lechner E. Imigrac¸a˜o e sau´de mental. Migracoes [Internet]. 2007[cited 2016 Jan 29]. http://www.ceg.ul.pt/migrare/publ/migracoes1_completo.pdf.5 Waldman TC. Movimentosmigrato´rios sob a perspectiva do direito a` sau´de:imigrantes bolivianas em Sa˜o Paulo. Rev Dir Sanit. 2011;12:90-114.6 Straiton M, Reneflot A, Diaz E. Immigrants’ use of primary health careservices for mental health problems. BMC Health Serv Res. 2014;14:341.A neurofeedback protocolto improve mild anxiety andsleep qualityRev. Bras. Psiquiatr. 2016;38:264-265doi:10.1590/1516-4446-2015-1811As most psychiatric disorders, anxiety and depressionare conditions whose severity can be represented overcontinuums that range from subclinical manifestations(expectancy/fear without proper justification and low mood,respectively) to full-blown biosocial disabilities. From anendophenotypic perspective, alpha band (8-12 Hz) asym-metry in the left frontal cortex has emerged as the mostprominent electroencephalographic (EEG) correlate of bothanxiety and depression in right-handed people, followed byexcessive band power in beta 1 (12-20 Hz) and beta 2waves (20-30 Hz) in the right parietal lobe.1 Shared featuresalso extend to the genetic level, where the presence ofcopies of the short variation of the 5-HTTLPR polymorphismincreases the risk of both anxiety and depression.EEG neurofeedback is an operant conditioning techniquein which subjects learn to self-regulate and modify their brainactivity through a feedback loop. In the recent past, inductionof healthy alpha asymmetry2,3 and regulation of alpha powerbands4 have been successfully used to treat anxiety anddepression, whereas increasing the power of sensorimotorrhythm (SMR) bands – a sort of EEG activity ranging from12-15 Hz over the sensorimotor cortex – has been usedsuccessfully to improve memory and sleep quality.5We report the case of a 29-year-old woman, with noprevious psychiatric history, who presented with anxietysymptoms, sleep problems, and mild cognitive impairmentswhich she associated to a contingent situation she wasfacing. We assessed pre- and post-EEG data usinga protocol reported elsewhere.3 Anxiety and depressionsymptoms were assessed using Beck scales (BeckAnxiety Inventory [BAI] and Beck Depression Inventory[BDI]), and sleep quality, with the Pittsburgh Sleep QualityIndex (PSQI). Cognitive measures were also administered.A summary of results is presented in Table 1.The training protocol lasted 20 sessions, during which thesubject was trained to increase beta 1 (12-15 Hz) at C4 witheyes open, followed by closed-eyes training designed toincrease the alpha/beta 3 ratio (9.5-12 Hz/23-38 Hz) at P4.There was marked improvement of anxiety, depression, andsleep quality, as well as some improvement in executivefunctions (Table 1). From an endophenotypic viewpoint,there was an overall increase in beta 1, low alpha (8-10 Hz),and high alpha (10-12 Hz) powers and a decrease in beta 2Rev Bras Psiquiatr. 2016;38(3)264 Letters to the Editors

It is time to prepare mental health services to attend to migrants and refugees

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It is time to prepare mental health services to attend to migrants and refugees

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