portuguese | english Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
JCR IF 2016: 2.049
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Is emotional functioning related to academic achievement among university students? Results from a cross-sectional Iranian sample
Dena Sadeghi Bahmani; Parviz Faraji; Robab Faraji; Undine E. Lang; Edith Holsboer-Trachsler; Serge Brand

OBJECTIVE: Whereas several studies have predicted academic achievement (AA) as a function of favorable cognitive factors and low negative emotional functioning (such as depression and anxiety), little is known about its associations with cognitive-emotional states of positive emotional functioning, such as social satisfaction. The present study sought to evaluate associations of AA with dimensions of negative and positive emotional functioning. METHOD: This cross-sectional study enrolled 275 students (mean age, 21.24 years; 66.1% females), who completed questionnaires covering sociodemographic parameters and AA scores, as well as measures of loneliness and depression (representing negative emotional functioning) and social satisfaction (representing positive emotional functioning). RESULTS: Lower scores for negative and higher scores for positive emotional functioning were associated with higher AA scores. Multiple regression analysis showed that AA was predicted independently by both low negative and high positive emotional functioning. No gender differences were observed. CONCLUSIONS: The pattern of results observed in this study suggests that opposing dimensions of emotional functioning are independently related to AA. Students, educators, and health professionals dealing with students should focus both on increasing social satisfaction and on decreasing feelings of loneliness and depression.

Descriptors: Negative emotions; positive emotions; students; academic achievement; loneliness; depression; social satisfaction

The slant of the forehead as a craniofacial feature of impulsiveness
J. David Guerrero-Apolo; J. Blas Navarro-Pastor; Antonio Bulbena-Vilarrasa; Julián Gabarre-Mir

OBJECTIVE: Impulsiveness has been the subject of much research, but little is known about the possible relationship between craniofacial anatomy and impulsiveness. The present study was designed to investigate the relationship between one aspect of craniofacial structure (the angle of inclination of the forehead) and impulsiveness. METHOD: Photographs in profile were obtained from 131 volunteers who had been fined for driving at high speed and were undergoing a court-mandated driving license point-recovery course. They completed the Barratt Impulsiveness Scale (BIS-11), the Impulsive Behavior Scale (UPPS-P), and Zuckerman's Sensation Seeking Scale (V). The angle of the slant of the forehead was measured with a photographic support and a protractor. RESULTS: High positive concordance was found between forehead inclination and 14 out of the 15 impulsiveness factors studied. CONCLUSIONS: The angle of inclination of the forehead was significantly associated with self-reported impulsiveness in this sample of traffic violators.

Descriptors: Craniofacial anatomy; impulsiveness; forehead; BIS-11

By the book: ADHD prevalence in medical students varies with analogous methods of addressing DSM items
Paulo Mattos; Bruno P. Nazar; Rosemary Tannock

OBJECTIVE: The marked increase in the prevalence of attention-deficit/hyperactivity disorder (ADHD) among university students gives rise to questions about how best to diagnose in this setting. The aim of the present study was to calculate ADHD prevalence in a large non-clinical sample of medical students using a stepwise design and to determine whether ADHD diagnosis varies if interviewees use additional probing procedures to obtain examples of positive DSM items. METHODS: A total of 726 students were screened with the Adult Self-Report Scale (ASRS) and invited for an interview with the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) adapted for adults. RESULTS: The ASRS was positive for 247 students (37%), although only 83 (7.9%) received an ADHD diagnosis. ASRS sensitivity and specificity rates were 0.97 and 0.40, respectively. Probing procedures were used with a subgroup of 226 students, which decreased the number of ADHD diagnoses to 12 (4.5%). CONCLUSION: Probing for an individual's real-life examples during the K-SADS interview almost halved ADHD prevalence rate based on the ASRS and K-SADS, which rendered the rate consistent with that typically reported for young adults. In reclassified cases, although examples of inattention did not match the corresponding DSM item, they often referred to another DSM inattention item.

Descriptors: ADHD; university services; student; diagnostic interviews; prevalence

Active Brazilian crack cocaine users: nutritional, anthropometric, and drug use profiles
Mariana Escobar; Juliana N. Scherer; Cassia M. Soares; Luciano S.P. Guimarães; Martine E. Hagen; Lisia von Diemen; Flavio Pechansky

OBJECTIVE: To evaluate the nutritional status of crack users and to analyze its correlation with drug use profiles. METHODS: Cross-sectional study with 108 crack users. Anthropometric data were assessed through body mass index (BMI) and bioimpedance (BIA) measurements. A blood test to analyze hematocrit, hemoglobin, glucose, and lipid profiles was also performed. Crack use was determined through a standardized interview. RESULTS: Based on BMI and BIA, most individuals were eutrophic (about 70%). Regarding hematological parameters, we found that hemoglobin and hematocrit levels were below normal for 32.4 and 30.6% of patients, respectively. Considering normal parameters, a large part of the sample (60.2%) had low levels of HDL cholesterol and high levels of triglycerides (38%). There were no significant correlations between drug profile and nutritional variables. CONCLUSION: This is a pioneering study that examines the nutritional status of crack users. Our results showed that most crack users present normal anthropometric findings and the prevalence of underweight is low. However, blood analysis showed changes and a specific type of malnutrition.

Descriptors: Crack cocaine; nutritional assessment; nutritional status; biochemical parameters

Religiosity, depression, and quality of life in bipolar disorder: a two-year prospective study
André Stroppa; Fernando A. Colugnati; Harold G. Koenig; Alexander Moreira-Almeida

OBJECTIVE: Few quantitative studies have examined the effect of religious involvement on the course of bipolar disorder (BD). We investigated the effects of religious activity and coping behaviors on the course of depression, mania, and quality of life (QoL) in patients with BD. METHODS: Two-year longitudinal study of 168 outpatients with BD. Linear regression was used to examine associations between religious predictors and outcome variables (manic symptoms, depression, QoL), controlling for sociodemographic variables. RESULTS: Among the 158 patients reassessed after 2 years, positive religious coping at T1 predicted better QoL across all four domains: physical (β = 10.2, 95%CI 4.2 to 16.1), mental (β = 13.4, 95%CI 7.1 to 19.7), social (β = 10.5, 95%CI 3.6 to 17.33), and environmental (β =11.1, 95%Ci 6.2 to 16.1) at T2. Negative religious coping at T1 predicted worse mental (β = -28.1, 95%CI -52.06 to -4.2) and environmental (β = -20.4, 95%CI -39.3 to -1.6) QoL. Intrinsic religiosity at T1 predicted better environmental QoL (β = 9.56, 95%CI 2.76 to 16.36) at T2. Negative religious coping at T1 predicted manic symptoms (β = 4.1) at T2. CONCLUSION: Religiosity/spirituality (R/S) may influence the QoL of patients with BD over time, even among euthymic patients. Targeting R/S (especially positive and negative religious coping) in psychosocial interventions may enhance the quality of recovery in patients with BD.

Descriptors: Bipolar disorder; religion; spirituality; quality of life; mania

Diagnosing dementia in lower educated older persons: validation of a Brazilian Portuguese version of the Rowland Universal Dementia Assessment Scale (RUDAS)
Narahyana B. de Araujo; Thomas R. Nielsen; Knut Engedal; Maria L. Barca; Evandro S. Coutinho; Jerson Laks

OBJECTIVE: To validate the Rowland Universal Dementia Assessment Scale for use in Brazil (RUDAS-BR). METHODS: We first completed an English-Brazilian Portuguese translation and back-translation of the RUDAS. A total of 135 subjects over 60 years of age were included: 65 cognitively healthy and 70 with Alzheimer's disease (AD) according to the DSM-IV and Neurological and Communicative Disorders and Stroke/Alzheimer's Disease and Related Disorders Association (NINCDS-ADRDA) criteria. All participants completed an interview and were screened for depression. The receiver operating characteristic curves of the RUDAS were compared with those of the Mini Mental State Examination (MMSE) regarding the sensitivity and specificity of cutoffs, taking education into consideration. RESULTS: The areas under the curve were similar for the RUDAS-BR (0.87 [95%CI 0.82-0.93]) and the MMSE (0.84 [95%CI 0.7-0.90]). RUDAS-BR scores < 23 indicated dementia, with sensitivity of 81.5% and specificity of 76.1%. MMSe < 24 indicated dementia, with sensitivity of 72.3% and specificity of 78.9%. The cutoff score was influenced by years of education on the MMSE, but not on the RUDAS-BR. CONCLUSIONS: The RUDAS-BR is as accurate as the MMSE in screening for dementia. RUDAS-BR scores were not influenced by education. The RUDAS-BR may improve the cognitive assessment of older persons who are illiterate or of lower educational attainment.

Descriptors: Dementia; Alzheimer's disease; education; psychiatric; tests/interviews; psychometric; cognitive neuroscience; diagnosis and classification

Virtual reality exposure therapy for fear of driving: analysis of clinical characteristics, physiological response, and sense of presence
Rafael T. da Costa; Marcele R. de Carvalho; Pedro Ribeiro; Antonio E. Nardi

OBJECTIVE: To investigate the reactions of women with driving phobia to a therapeutic program of scheduled virtual reality exposure treatment (VRET) sessions. METHODS: The study intervention consisted of a computer game with car-driving scenarios that included several traffic situations. We investigated the participants' sense of presence, subjective distress, and physiological responses during eight virtual-reality exposures. We also evaluated clinical characteristics, driving cognitions, and quality of life in the participants. RESULTS: Thirteen women were selected. Eight were able to complete the protocol. After VRET, there was a decrease in the frequency of distorted thoughts and state anxiety scores, as well as a slight improvement in quality of life. Subjective discomfort scores, heart rate variation, and sense of presence scores confirmed that there was sense of presence in the virtual reality environment. CONCLUSION: All patients showed some degree of improvement and demonstrated different levels of anxiety in subsequent in vivo driving experiences. Our findings suggest that VRET could be used to facilitate in vivo exposure, because it can induce presence/immersion and reduce anxiety in patients with specific phobia. Furthermore, VRET is not associated with any type of risk.

Descriptors: Virtual reality; behavior therapy; fear of driving

Psychoactive substance abuse and dependence and its association with anxiety disorders: a population-based study of young adults in Brazil
Mariana B. de Matos; Christian L. de Mola; Jéssica P. Trettim; Karen Jansen; Ricardo A. da Silva; Luciano D. de Mattos Souza; Liliane da Costa Ores; Mariane L. Molina; Fernanda T. Coelho; Ricardo T. Pinheiro; Luciana de A. Quevedo

OBJECTIVE: To evaluate the association between abuse of and dependence on different psychoactive substances and the presence of anxiety disorders in a sample of young adults from a city in southern Brazil. METHODS: Between 2007 and 2009, we carried out a cross-sectional, population-based study of individuals aged 18-24 years who lived in Pelotas, a city in southern Brazil. We evaluated anxiety disorders using the Mini International Neuropsychiatric Interview 5.0 (MINI), and use of psychoactive substances with the Alcohol, Smoking, and Substance Involvement Screening Test (ASSiSt 2.0/0MS). We used Fisher's exact test for univariate analysis, and Poisson regression models with robust variance for multivariable analysis. RESULTS: The sample consisted of 1,560 young adults. The overall prevalence of abuse/dependence was 26.9% for alcohol, 24.9% for tobacco, and 7.3% for illicit substances. Individuals with agoraphobia had a 32% higher prevalence of tobacco abuse/dependence (prevalence ratio [PR] = 1.32 [95%CI 1.01-1.74]). Individuals with posttraumatic stress disorder (PTSD) or generalized anxiety disorder (GAD) had a 2.41-fold (95%CI 1.22-4.77) and 1.76-fold (95%CI 1.00-3.11) higher prevalence of illicit substance abuse/dependence, respectively. CONCLUSION: In this population-based sample, we found associations between GAD, PTSD, and increased prevalence of illicit substance abuse/dependence. In addition, individuals with agoraphobia seem to have increased tobacco abuse/dependence.

Descriptors: Epidemiology; adolescents; alcohol abuse; anxiety disorder, generalized; adult development

Exposure to violence: associations with psychiatric disorders in Brazilian youth
Thiago M. Fidalgo; Zila M. Sanchez; Sheila C. Caetano; Solange Andreoni; Adriana Sanudo; Qixuan Chen; Sílvia S. Martins

OBJECTIVE: The effects of exposure to violent events in adolescence have not been sufficiently studied in middle-income countries such as Brazil. The aims of this study are to investigate the prevalence of psychiatric disorders among 12-year-olds in two neighborhoods with different socioeconomic status (SES) levels in São Paulo and to examine the influence of previous violent events and SES on the prevalence of psychiatric disorders. METHODS: Students from nine public schools in two neighborhoods of São Paulo were recruited. Students and parents answered questions about demographic characteristics, SES, urbanicity and violent experiences. All participants completed the Kiddie Schedule for Affective Disorders and Schizophrenia (K-SADS) to obtain DSM-IV diagnoses. The data were analyzed using weighted logistic regression with neighborhood stratification after adjusting for neighborhood characteristics, gender, SES and previous traumatic events. RESULTS: The sample included 180 individuals, of whom 61.3% were from low SES and 39.3% had experienced a traumatic event. The weighted prevalence of psychiatric disorders was 21.7%. Having experienced a traumatic event and having low SES were associated with having an internalizing (adjusted OR = 5.46; 2.17-13.74) or externalizing disorder (adjusted OR = 4.33; 1.85-10.15). CONCLUSIONS: Investment in reducing SES inequalities and preventing violent events during childhood may improve the mental health of youths from low SES backgrounds.

Descriptors: Adolescents; child psychiatry; epidemiology; social and political issues; violence/aggression

Validation of the Mnemonic Similarity Task - Context Version
Giulia A. Aldi; Iris Lange; Cristiana Gigli; Lies Goossens; Koen R. Schruers; Fiammetta Cosci

OBJECTIVE: Pattern separation (PS) is the ability to represent similar experiences as separate, nonoverlapping representations. It is usually assessed via the Mnemonic Similarity Task - Object Version (MST-O) which, however, assesses PS performance without taking behavioral context discrimination into account, since it is based on pictures of everyday simple objects on a white background. We here present a validation study for a new task, the Mnemonic Similarity Task - Context Version (MST-C), which is designed to measure PS while taking behavioral context discrimination into account by using real-life context photographs. METHODS: Fifty healthy subjects underwent the two MST tasks to assess convergent evidence. Instruments assessing memory and attention were also administered to study discriminant evidence. The test-retest reliability of MST-C was analyzed. RESULTS: Weak evidence supports convergent validity between the MST-C task and the MST-O as measures of PS (rs = 0.464; p < 0.01); PS performance assessed via the MST-C did not correlate with memory or attention; a moderate test-retest reliability was found (rs = 0.595; p < 0.01). CONCLUSION: The MST-C seems useful for assessing PS performance conceptualized as the ability to discriminate complex and realistic spatial contexts. Future studies are welcome to evaluate the validity of the MST-C task as a measure of PS in clinical populations.

Descriptors: Pattern separation; context discrimination; mnemonic similarity task; Mnemonic Similarity Task - Object Version; Behavioral Pattern Separation Task

Clinical practice guidelines for post-stroke depression in China
Fu-ying Zhao*; Ying-ying Yue*; Lei Li*; Sen-yang Lang; Ming-wei Wang; Xiang-dong Du; Yun-long Deng; Ai-qin Wu; Yong-gui Yuan

Post-stroke depression (PSD) is a very common complication that leads to increased physical disability, poor functional outcome, and higher mortality. Therefore, early detection and treatment are very important. Since there are currently no specific guidelines for this disorder in China, the purpose of this study was to develop PSD guidelines and provide suggestions for clinicians and related workers.

Descriptors: Post-stroke depression; diagnosis; treatment

The presentation of the mind-brain problem in leading psychiatry journals
Alexander Moreira-Almeida; Saulo de F. Araujo; C. Robert Cloninger

OBJECTIVE: The mind-brain problem (MBP) has marked implications for psychiatry, but has been poorly discussed in the psychiatric literature. This paper evaluates the presentation of the MBP in the three leading general psychiatry journals during the last 20 years. METHODS: Systematic review of articles on the MBP published in the three general psychiatry journals with the highest impact factor from 1995 to 2015. The content of these articles was analyzed and discussed in the light of contemporary debates on the MBP. RESULTS: Twenty-three papers, usually written by prestigious authors, explicitly discussed the MBP and received many citations (mean = 130). The two main categories were critiques of dualism and defenses of physicalism (mind as a brain product). These papers revealed several misrepresentations of theoretical positions and lacked relevant contemporary literature. Without further discussion or evidence, they presented the MBP as solved, dualism as an old-fashioned or superstitious idea, and physicalism as the only rational and empirically confirmed option. CONCLUSION: The MBP has not been properly presented and discussed in the three leading psychiatric journals in the last 20 years. The few articles on the topic have been highly cited, but reveal misrepresentations and lack of careful philosophical discussion, as well as a strong bias against dualism and toward a materialist/physicalist approach to psychiatry.

Descriptors: Body-mind relations; psychiatry; philosophy; neurosciences; neuropsychiatry

Psychiatric disorders in adolescents with type 1 diabetes: a case-control study
Mireille C. Almeida; Denise A. Claudino; Ruth B. Grigolon; Bacy Fleitlich-Bilyk; Angélica M. Claudino

OBJECTIVES: To study the prevalence of psychiatric disorders in adolescents with and without type 1 diabetes, the factors associated with its presence, and to test the reliability of a screening tool for use in clinical settings. METHODS: Eighty-one adolescents were enrolled in this case-control study, including 36 diabetic participants and 45 controls. Clinical and sociodemographic data were collected and psychiatric symptoms and diagnoses were obtained from adolescents and their parents using a screening tool (Strengths & Difficulties Questionnaire) and a semi-structured interview (Development and Well-Being Assessment). RESULTS: Psychiatric disorders were identified in 22.2% of the sample (30.56% among diabetic adolescents vs. 15.56% of controls: OR = 2.39, 95%CI 0.82-6.99; p = 0.11). Overweight (body mass index percentile ≥ 85) was the only factor associated with psychiatric disorder (OR = 3.07; 95%C11.03-9.14; p = 0.04). Compared to the semi-structured interview, the screening instrument showed 80% sensitivity, 96% specificity, 88.9% positive predictive value and 92.3% negative predictive value for the presence of psychiatric diagnoses in adolescents. CONCLUSION: Psychiatric morbidity was high in this sample of adolescents, especially among those with diabetes. Routine use of the Strengths and Difficulties Questionnaire can help with early detection of psychiatric disorders in this at-risk group.

Descriptors: Adolescent; epidemiology; child psychiatry; diabetes mellitus; type 1

Art therapy as an adjuvant treatment for depression in elderly women: a randomized controlled trial
Eliana C. Ciasca; Rita C. Ferreira; Carmen L.A. Santana; Orestes V. Forlenza; Glenda D. dos Santos; Paula S. Brum; Paula V. Nunes

OBJECTIVE: There are few quantitative studies on art therapy for the treatment of depression. The objective of this study was to evaluate if art therapy is beneficial as an adjuvant treatment for depression in the elderly. METHODS: A randomized, controlled, single-blind study was carried out in a sample of elderly women with major depressive disorder (MDD) stable on pharmacotherapy. The experimental group (EG) was assigned to 20 weekly art therapy sessions (90 min/session). The control group (CG) was not subjected to any adjuvant intervention. Patients were evaluated at baseline and after 20 weeks, using the Geriatric Depression Scale (GDS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and cognitive measures. RESULTS: Logistic regression analysis adjusted for age revealed that women in EG (n=31) had significant improvement in GDS (p = 0.007), BDI (p = 0.025), and BAI (p = 0.032) scores as compared with controls (n=25). No difference was found in the cognitive measures. CONCLUSION: Art therapy as an adjunctive treatment for MDD in the elderly can improve depressive and anxiety symptoms. CLICINAL TRIAL REGISTRATION: RBR-2YXY7Z

Descriptors: Art therapy; depression; anxiety; elderly patients; clinical trial

Gender differences of cannabis smoking on serum leptin levels: population-based study
Fernanda P. Moreira; Carolina D. Wiener; Jacqueline F. de Oliveira; Luciano D.M. Souza; Ricardo A. da Silva; Luis V. Portela; Diogo R. Lara; Karen Jansen; Jean Pierre Oses

OBJECTIVE: To evaluate the serum leptin levels in cannabis smokers. METHODS: This was a cross-sectional population-based study of participants between the ages of 18 and 35 years. The data were collected through a self-administered questionnaire covering sociodemographic data and the use of psychoactive substances. Leptin levels were measured using a commercial ELISA kit. RESULTS: Of the 911 participants, 6.7% were identified as cannabis smokers and had significantly lower leptin levels (p = 0.008). When stratified by gender, there was a significant decrease in leptin levels among male smokers (p = 0.039). CONCLUSION: Cannabis smoking was linked to leptin levels in men, suggesting that the response to biological signals may be different between men and women.

Descriptors: Cannabis sativa; leptin; young adults; gender

Profile and costs involved in long-term compulsory hospitalization of psychiatric patients
Fernando Venturini; Eduardo C. de Moura; Paula A. Bastos; Lourdes C. Martins; Yara D. Fragoso

OBJECTIVE: Involuntary hospitalization for acute psychiatry cases can be acceptable when there is potential harm. However, there are few reasons for a patient committed on these grounds to stay in an institution for a long period. The objective of the present study was to identify the profile and costs of compulsory hospitalizations over 20 days in a public psychiatric hospital in the coastal region of the state of Sao Paulo. METHODS: Retrospective data were collected from the medical records of 1,064 patients admitted between July 2013 and June 2016 from an intensive mental healthcare unit in Santos, state of São Paulo, Brazil. RESULTS: Records were found of 527 patients who had been hospitalized for at least 21 days during the study period. Long-term hospitalization related to judicial mandates represented 5.9% of the total sample. These patients stayed in the hospital for an average period of 142 days, while patients hospitalized for any other reason stayed an average period of 35 days (p < 0.001). The cost of a longterm court-ordered hospitalization averaged US$ 21,311 per patient. CONCLUSION: Judicial mandate has been an important reason for the long-term hospitalization of chronic psychiatric patients in Santos, Brazil.

Descriptors: Chronic psychiatric disease; hospitalization; psychiatry hospital; drug abuse; psychosis

Introducing care management to Brazil's alcohol and substance use disorder population
Ilana Pinsky; Camila Bernal; Lindsey Vuolo; Charles Neighbors

Brazil has a sizable alcohol and substance use disorder (ASUD) population, yet there are considerable gaps in treatment access and retention. ASUD, a chronic medical condition, is highly comorbid with medical and behavioral health disorders. This indicates a need for more targeted interventions in order to achieve health care integration (a major goal of Brazil's health care system). Care management - that is, the organization of patient care by an institution - is a viable strategy to engage individuals with ASUD who might benefit from treatment but are not aware of or do not use the available resources, as well as to help maintain patients in treatment. Care management is considered an essential supplement to the treatment of chronic disease. The objective of this article is to discuss the applicability of care management for the treatment of ASUD within the public health care system in Brazil. We describe models of care management that have been adopted internationally and identify the feasibility and advantages for its adoption in Brazil.

Descriptors: care management; substance use; Brazil; treatment integration

Conceptions and practices of an integrative treatment for substance use disorders involving Amazonian medicine: traditional healers' perspectives
Ilana Berlowitz; Christian Ghasarian; Heinrich Walt; Fernando Mendive; Vanessa Alvarado; Chantal Martin-Soelch

OBJECTIVE: The harmful use of psychoactive substances represents one of today's largest public health problems. Yet, in spite of its global relevance, current treatment for substance use disorders (SUDs) is still not entirely successful. The purpose of this study was to investigate alternative treatments and conceptions from traditional Amazonian medicine adapted to SUDs. METHODS: We conducted semi-structured interviews with 13 practicing experts at a well-established addiction treatment center in the Peruvian Amazon and performed qualitative content analysis on the collected data. Main categories were deductively defined and corresponding subcategories inductively developed. RESULTS: Our findings revealed characteristic features and consequences, causes and antecedents, and treatment methods of SUDs as the main categories. Overall, concepts of disease etiology bore resemblance with contemporary biopsychosocial models of SUDs. The Amazonian therapeutic means however differed markedly from current Western ones. The main methods involved dietary retreats, healing ceremonies, and purging rituals. The integral application of Amazonian methods, as well as their traditional implementation according to prescribed ritual protocols, were emphasized by the experts as crucial for efficacy and safety of treatment delivery. CONCLUSION: We suggest further scientific attention to these therapies, including clinical studies, for which our results provide conceptual underpinnings. Findings from this research expand the cross-cultural understanding of SUDs and, in the long run, may enhance its treatment options.

Descriptors: Substance use disorders; addiction; traditional Amazonian medicine; illness concepts; expert interviews; addiction treatment; alternative medicine; Peru; Amazon

Impact of a provider training program on the treatment of children with autism spectrum disorder at psychosocial care units in Brazil
Luciana C. Silva; Maria C.T.V. Teixeira; Edith L. Ribeiro; Cristiane S. Paula

OBJECTIVE: To develop, implement, and verify the impact of a training program for health care providers working with children with autism spectrum disorder (ASD) in psychosocial care centers for children and adolescents (Centro de Atenção Psicossocial à Infancia e à Adolescencia - CAPSi) in São Paulo, Brazil. METHODS: This quasi-experimental study was conducted with 14 professionals from four CAPSi units. The training program consisted of six phases: 1) pre-intervention observation; 2) meeting with staff to assess the main needs of the training program; 3) developing materials for training and evaluation; 4) meetings to discuss program implementation; 5) a final meeting for case discussion and evaluation; and 6) distance supervision. Three measures were used to evaluate the training program: i) the Knowledge, Attitudes, and Practices (KAP) questionnaire; ii) videos containing questions designed to assess program comprehension; and iii) a satisfaction survey. RESULTS: Thirteen videos were produced to as visual aids for use during the training program, and a further 26 videos were developed to evaluate it. The program was well evaluated by the participants. The video responses and kAp questionnaire scores suggest that staff knowledge and attitudes improved after training. CONCLUSION: The positive findings of this study suggest that the tested training program is feasible for use with multidisciplinary teams working in the CAPSi environment.

Descriptors: Child psychiatry; autism; community mental health; education, psychiatric; interdisciplinary relations

Effects of N-acetylcysteine on amphetamine-induced sensitization in mice
Ana P. Herrmann; Roberta Andrejew; Radharani Benvenutti; Clarissa S. Gama; Elaine Elisabetsky

OBJECTIVE: N-acetylcysteine (NAC) is beneficial in psychiatric conditions, including schizophrenia. Patients with schizophrenia exhibit mesolimbic dopamine hyperfunction consequent to an endogenous sensitization process. This sensitization can be modeled in rodents by repeated exposure to psychostimulants, provoking an enduring amplified response at subsequent exposure. The aim of this study was to investigate the effects of NAC on amphetamine sensitization in mice. METHODS: D-amphetamine was administered to C57BL/6 mice three times a week for 3 weeks; the dose was increased weekly from 1 to 3 mg/kg. NAC (60 mg/kg) or saline was administered intra-peritoneally before saline or amphetamine during the second and third weeks. After a 4-week washout period, latent inhibition (LI) and the locomotor response to amphetamine 2 mg/kg were assessed. RESULTS: Sensitization disrupted LI and amplified the locomotor response; NAC disrupted LI in control mice. In sensitized animals, NAC attenuated the enhanced locomotion but failed to prevent LI disruption. CONCLUSION: NAC warrants consideration as a candidate for early intervention in ultra-high risk subjects due to its safety profile and the relevance of its mechanism of action. Supplementing this proposition, we report that NAC attenuates sensitization-induced locomotor enhancement in mice. The finding that NAC disrupted LI incites a cautionary note and requires clarification.

Descriptors: Schizophrenia; acetylcysteine; amphetamine

Intermittent theta-burst transcranial magnetic stimulation for autism spectrum disorder: an open-label pilot study
Caio Abujadi; Paul E. Croarkin; Bianca B. Bellini; Helena Brentani; Marco A. Marcolin

OBJECTIVE: Theta-burst stimulation (TBS) modulates synaptic plasticity more efficiently than standard repetitive transcranial magnetic stimulation delivery and may be a promising modality for neuropsychiatric disorders such as autism spectrum disorder (ASD). At present there are few effective interventions for prefrontal cortex dysfunction in ASD. We report on an open-label, pilot study of intermittent TBS (iTBS) to target executive function deficits and restricted, repetitive behaviors in male children and adolescents with ASD. METHODS: Ten right-handed, male participants, aged 9-17 years with ASD were enrolled in an open-label trial of iTBS treatment. Fifteen sessions of neuronavigated iTBS at 100% motor threshold targeting the right dorsolateral prefrontal cortex were delivered over 3 weeks. RESULTS: Parent report scores on the Repetitive Behavior Scale Revised and the Yale-Brown Obsessive Compulsive Scale demonstrated improvements with iTBS treatment. Participants demonstrated improvements in perseverative errors on the Wisconsin Card Sorting Test and total time for the Stroop test. The iTBS treatments were well tolerated with no serious adverse effects. CONCLUSION: These preliminary results suggest that further controlled interventional studies of iTBS for ASD are warranted.

Descriptors: Autism spectrum disorder; intermittent theta burst stimulation; noninvasive brain stimulation; theta-burst stimulation; repetitive transcranial magnetic stimulation

Brazilian version of the Cognitive Failures Questionnaire (CFQ): cross-cultural adaptation and evidence of validity and reliability
Jonas J. de Paula; Danielle S. Costa; Débora M. de Miranda; Marco A. Romano-Silva

OBJECTIVE: Cognitive failures are simple mistakes in routine activities, such as forgetting commitments and experiencing difficulty concentrating. The Cognitive Failures Questionnaire (CFQ) was designed to assess the frequency of these errors in everyday life. Although widely used in psychiatry and psychology, both in clinical and research settings, it has not been adapted for use in Brazil. Our objective was to perform cross-cultural adaptation of the CFQ for the Brazilian reality and assess its validity and reliability. METHODS: The original version of the CFQ was translated into Brazilian Portuguese by two independent researchers, analyzed by a multidisciplinary board of experts, and back-translated into English. The final version was administered to 225 adults. Validity was assessed by correlation with the Self Reporting Questionnaire-20 (SRQ-20) and the Adult Attention Deficit/Hyperactivity Disorder SelfReport Scale (ASRS-18). Reliability was analyzed by calculating internal consistency and test-retest stability. RESULTS: The adapted version of the CFQ showed significant correlations with SRQ-20 (r = -0.311), ASRS-18 inattention (r = 0.696), and hyperactivity/impulsivity (r = 0.405) scores. Reliability analysis suggests high internal consistency (0.906) and temporal stability (0.813). CONCLUSION: The Brazilian Portuguese version of the CFQ showed moderate correlations with other measures of mental health, as well as adequate reliability.

Descriptors: Cognitive neuroscience; diagnosis and classification; memory; occupational psychiatry; psychometric tests/interviews

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