portuguese | english Revista Brasileira de Psiquiatria ISSN print 1516-4446
ISSN on-line 1809-452X
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Current issue 2, Volume 37 - Apr/May/Jun/2015


1 - The prevalence of bipolar disorders in the general population: a growing trending topic?
Vicent Balanzá-Martínez; Rafael Tabarés-Seisdedos
Pages: 91 - 92


2 - Relationship of cortisol, norepinephrine, and epinephrine levels with war-induced posttraumatic stress disorder in fathers and their offspring
Seyyed Taha Yahyavi; Mehran Zarghami; Farshad Naghshvar; Ahmad Danesh
Pages: 93 - 98

OBJECTIVE: To compare afternoon serum/plasma levels of hormones in four groups: (A) veterans with posttraumatic stress disorder (PTSD), (B) offspring of PTSD veterans, (C) veterans without PTSD, and (D) offspring of non-PTSD veterans.
METHODS: Evaluation consisted of a semi-structured interview for axis I and II diagnoses, followed by measurement of afternoon serum cortisol and plasma epinephrine and norepinephrine by ELISA (Diametra) and LND (LDN Labor Diagnostika Nord GmbH & Co. KG) respectively. Data were analyzed using descriptive statistics and the Student t, Kolmogorov-Smirnov, and nonparametric Mann-Whitney tests.
RESULTS: One hundred and sixty-eight volunteers were investigated across the four groups. The groups were similar in terms of demographic characteristics, war experience and traumatization, and psychiatric and medical conditions other than PTSD (group A was similar to group C and group B was similar to group D). Between-groups comparisons did not yield statistically significant differences. Post-hoc analyses revealed significant differences in afternoon cortisol level between the offspring of veterans with current/past history of PTSD and the offspring of veterans without a history of PTSD.
CONCLUSION: We only found decreased cortisol levels in offspring of veterans after rearranging the groups to reflect previous history of PTSD. Further studies are required to investigate the relationship between cortisol levels and the transgenerational effects of trauma and parental PTSD.

Descriptors: Epinephrine; norepinephrine; cortisol; posttraumatic stress disorder; offspring

3 - Sports practices related to alcohol and tobacco use among high school students
André Bedendo; Ana R. Noto
Pages: 99 - 105

OBJECTIVE: To examine the relationship between alcohol and tobacco use and sports in a national sample of secondary students.
METHODS: This cross-sectional study enrolled a representative sample of secondary students from public and private schools from all 27 Brazilian state capitals. Students were assessed in 2010 by a self-report questionnaire including questions on drug use and sport activity in the last month (n=13,872).
RESULTS: Subjects who played sports exhibited a higher frequency of alcohol use and heavy episodic drinking than their peers who did not play sports. Practices that were associated with higher odds of heavy episodic drinking in the last month included gym, weight training (adjusted odds ratio [aOR]: 2.0, 95% confidence interval [95%CI] 1.6-2.4), and soccer (aOR: 1.3, 95%CI 1.1-1.5). Fighting, martial arts, or capoeira were associated with smoking (aOR: 1.9, 95%CI 1.2-3.2).
CONCLUSION: These results suggest a relationship between some sports preferences and a higher risk of alcohol or tobacco use among Brazilian secondary students. This relationship should be considered in preventive programs.

Descriptors: Sports; exercise; alcohol drinking; tobacco; adolescent

4 - Metabolic syndrome and related variables, insulin resistance, leptin levels, and PPAR-γ2 and leptin gene polymorphisms in a pedigree of subjects with bipolar disorder
Trino Baptista; Ignacio Sandia; Erika Fernandez; Ligia Balzán; Lissette Connell; Euderruh Uzcátegui; Ana Serrano; Albis Pabón; Félix Angeles; Yarira Araque; Heidy Delgado; Alexy González; Yonathan Alviarez; Jose Piñero; Enma A. de Baptista
Pages: 106 - 112

OBJECTIVE: Evidence points to a high prevalence of metabolic dysfunction in bipolar disorder (BD), but few studies have evaluated the relatives of subjects with BD. We conducted a cross-sectional study in an extended family of patients with BD type I.
METHODS: The available relatives of the same family were interviewed (DSM-IV-R) and assessed in fasting conditions for body mass index, constituent variables of the metabolic syndrome (MS), leptin levels, insulin resistance index, and single nucleotide polymorphisms (SNPs) for the leptin receptor and promoter and PPAR-γ2 genes. The frequency of MS was compared with that recorded in the local general population.
RESULTS: Ninety-three relatives of three adults with BD were evaluated (30 aged < 18 years, 63 aged > 18 years). The frequency of MS was similar to that of the general population. Significantly higher frequencies of abnormal glucose, total and low density cholesterol (LDL-c) levels (all p < 0.05), waist circumference (p = 0.057), and leptin and insulin resistance values (in adults only) were observed in the family. Adults with the QQ genotype of the leptin receptor displayed higher LDL-c levels than carriers of the R allele.
CONCLUSIONS: The associations among BD consanguinity, familial hypercholesterolemia, and leptin receptor SNPs reported herein should be replicated and extended in other pedigrees.

Descriptors: Bipolar disorder; familiar hypercholesterolemia; insulin sensitivity; leptin; metabolic syndrome

5 - Serum concentrations of brain-derived neurotrophic factor and mental disorders in imprisoned women
Renata M. Dotta-Panichi; Helena D. Bins; Juliana F. Tramontina; Keila M. Ceresér; Bianca W. de Aguiar; André C. Paz; José G. Taborda
Pages: 113 - 120

OBJECTIVE: Mental disorders and early trauma are highly prevalent in female inmates. Brain-derived neurotrophic factor (BDNF) plays an important role in learning, memory processes, and mood regulation. The aim of this study was to evaluate the relationship between serum BDNF levels and mental disorders among imprisoned women as compared with age- and education-matched controls.
METHODS: A consecutively recruited sample of 18 female prisoners with mental disorders was assessed for sociodemographic, criminal, and clinical variables using standardized instruments, the Mini International Neuropsychiatric Interview Plus (MINI Plus), and serum BDNF levels.
RESULTS: High rates of childhood sexual abuse and posttraumatic stress disorder (PTSD) were found in the group of forensic patients. Serum BDNF levels in the forensic group did not differ from those of healthy controls, and were significantly higher when compared with those of women with mental disorders hospitalized in a general hospital.
CONCLUSION: Elevated serum BDNF levels were found in imprisoned women. The results of this study may suggest neurobiological mechanisms similar to those seen in previous clinical and preclinical studies showing the involvement of BDNF in the pathophysiology of PTSD.

Descriptors: Posttraumatic stress disorder; prisons; women; violence; aggression; biological markers

6 - Pharmacological treatment and staging in bipolar disorder: evidence from clinical practice
Pedro D. Goi; Joana Bücker; Mireia Vianna-Sulzbach; Adriane R. Rosa; Iria Grande; Ines Chendo; Leonardo A. Sodré; Marcia Kauer-Sant'Anna; Leonardo Silveira; Mauricio Kunz,; Keila M. Ceresér; Clarissa S. Gama; Raffael Massuda
Pages: 121 - 125

OBJECTIVE: Staging models for medical diseases are widely used to guide treatment and prognosis. Bipolar disorder (BD) is a chronic condition and it is among the most disabling disorders in medicine. The staging model proposed by Kapczinski in 2009 presents four progressive clinical stages of BD. Our aim was to evaluate pharmacological maintenance treatment across these stages in patients with BD.
METHODS: One hundred and twenty-nine subjects who met DSM-IV criteria for BD were recruited from the Bipolar Disorders Program at Hospital de Clinicas de Porto Alegre, Brazil. All patients were in remission. The subjects were classified according to the staging model: 31 subjects were classified as stage I, 44 as stage II, 31 as stage III, and 23 as stage IV.
RESULTS: Patterns of pharmacological treatment differed among the four stages (p = 0.001). Monotherapy was more frequent in stage I, and two-drug combinations in stage II. Patients at stages III and IV needed three or more medications or clozapine. Impairment in functional status (Functioning Assessment Short Test [FAST] scale scores) correlated positively with the number of medications prescribed.
CONCLUSIONS: This study demonstrated differences in pharmacological treatment in patients with stable BD depending on disease stage. Treatment response can change with progression of BD. Clinical guidelines could consider the staging model to guide treatment effectiveness.

Descriptors: Bipolar mood disorders; anticonvulsants; antidepressants; antipsychotics; diagnosis and classification

7 - Neuropsychological dysfunction in adults with early-onset obsessive-compulsive disorder: the search for a cognitive endophenotype
Jie Zhang; Xiaoping Yang; Qiyong Yang
Pages: 126 - 132

OBJECTIVE: Evidence suggests that early-onset obsessive-compulsive disorder (OCD) is an etiologically distinct subtype of OCD. The objective of the present work was to search for neurocognitive endophenotypes of early-onset OCD based on assessments of attention, memory, and executive function in patients with the disorder and their unaffected siblings.
METHODS: We compared the performance of 40 adult patients with early-onset OCD, 40 of their unaffected siblings, and 40 unrelated healthy controls on a neuropsychological battery designed for this study. We searched for associations among test performance, demographic variables (age, sex and years of education) and clinical symptoms of early-onset OCD.
RESULTS: Patients performed significantly worse than healthy controls on the Tower of Hanoi, and the Stroop and Wisconsin tests, indicating impairments in planning, mental flexibility and inhibitory control. The performance of the unaffected first-degree siblings of patients with early-onset OCD on the Stroop and Wisconsin tests also differed from that of healthy controls. Symptom severity in early-onset OCD was strongly correlated with performance on the Tower of Hanoi.
CONCLUSIONS: Our findings support the existence of specific executive function deficits in patients with early-onset OCD. Relatives presented an intermediate phenotype between patients and controls, suggesting that executive functions such as mental flexibility and response inhibition may be considered candidate endophenotypes of early-onset OCD.

Descriptors: Executive functions; endophenotype; mental flexibility; response inhibition; obsessive-compulsive disorder

8 - Attentional blink in children with attention deficit hyperactivity disorder
Juan A. Amador-Campos; J. Antonio Aznar-Casanova; Izabela Bezerra; Nelson Torro-Alves; Manuel M. Sánchez
Pages: 133 - 138

OBJECTIVE: To explore the temporal mechanism of attention in children with attention deficit hyperactivity disorder (ADHD) and controls using a rapid serial visual presentation (RSVP) task in which two letters (T1 and T2) were presented in close temporal proximity among distractors (attentional blink [AB]).
METHOD: Thirty children aged between 9 and 13 years (12 with ADHD combined type and 18 controls) took part in the study. Both groups performed two kinds of RSVP task. In the single task, participants simply had to identify a target letter (T1), whereas in the dual task, they had to identify a target letter (T1) and a probe letter (T2).
RESULTS: The ADHD and control groups were equivalent in their single-task performance. However, in the dual-task condition, there were significant between-group differences in the rate of detection of the probe letter (T2) at lag + 1 and lag + 4. The ADHD group exhibited a larger overall AB compared with controls.
CONCLUSION: Our findings provide support for a link between ADHD and attentional blink.

Descriptors: Visual attention deficit; attentional disorders; ADHD; attentional blink; visual perception

9 - Two clusters of child molesters based on impulsiveness
Danilo A. Baltieri; Douglas P. Boer
Pages: 139 - 145

OBJECTIVE: High impulsiveness is a general problem that affects most criminal offenders and is associated with greater recidivism risk. A cluster analysis of impulsiveness measured by the Barratt Impulsiveness Scale - Version 11 (BIS-11) was performed on a sample of hands-on child molesters.
METHODS: The sample consisted of 208 child molesters enrolled in two different sectional studies carried out in São Paulo, Brazil. Using three factors from the BIS-11, a k-means cluster analysis was performed using the average silhouette width to determine cluster number. Direct logistic regression was performed to analyze the association of criminological and clinical features with the resulting clusters.
RESULTS: Two clusters were delineated. The cluster characterized by higher impulsiveness showed higher scores on the Sexual Screening for Pedophilic Interests (SSPI), Static-99, and Sexual Addiction Screening Test.
CONCLUSIONS: Given that child molesters are an extremely heterogeneous population, the "number of victims" item of the SSPI should call attention to those offenders with the highest motor, attentional, and non-planning impulsiveness. Our findings could have implications in terms of differences in therapeutic management for these two groups, with the most impulsive cluster benefitting from psychosocial strategies combined with pharmacological interventions.

Descriptors: Child molesters; pedophilia; impulsiveness; cluster analysis

10 - Suicide among physicians in the state of São Paulo, Brazil, across one decade
Hamer N. Palhares-Alves; Daniel M. Palhares; Ronaldo Laranjeira; Luiz A. Nogueira-Martins; Zila M. Sanchez
Pages: 146 - 149

OBJECTIVE: To describe mortality by suicide among physicians in the state of São Paulo, Brazil, between 2000 and 2009.
METHODS: Secondary analysis of government mortality data. The variable of interest was "underlying cause of death", specifically deaths classified by the ICD-10 as intentional self-harm (X60 to X84).
RESULTS: The analyses examined 2,297 declarations of death, among which suicide accounted for 50 cases, i.e., 1.7% of all causes of death. Women comprised 13.2% of the total sample and represented 24% of the death-by-suicide group, indicating an overrepresentation of women in the latter (p = 0.02). Deaths by suicide occurred on average 20 years earlier than deaths by other causes (46.8±14.2 years and 68.1±15.8 years, respectively; p = 0.001). There was a significant association between single and/or divorced status and suicide (p < 0.001). The average mortality rate during the study period was 4.2 deaths per 100,000 physicians registered with the Regional Board of Medicine of the State of São Paulo.
CONCLUSION: Deaths by suicide occurred 20 years earlier than deaths by other causes. Medical institutions should develop strategies for the prevention and early detection of mental disorders and occupational stressors that elevate the risk of suicide among physicians.

Descriptors: Suicide; physicians; mortality; epidemiology; occupational psychiatry

11 - Profile of Brazilian smokers in the National Program for Tobacco Control
Nádia C. Rodrigues; Regina D. Neves; Daniela de S. Mendes; Cristiane P. Mendes; Isa H. Martins; Ines N. Reis; Valeria T. Lino; Gisele O'Dwyer; Regina P. Daumas; Tania Maria Esteves; Mônica K. Andrade; Denise L. Monteiro; Mônica B. Barros
Pages: 150 - 154

OBJECTIVE: The treatment of tobacco addiction in Brazil has expanded in recent years; however, we must increase knowledge about the characteristics of individuals who adhere to cessation programs in order to adjust treatments to specific characteristics of the target population that favor success. The aim of this study was to describe the characteristics of smokers who present to Brazilian public health units seeking help to quit smoking based on the experience of a primary health care unit that covers a poor community in the city of Rio de Janeiro.
METHODS: Data were collected at a Teaching Health Center from January 03 2012 to January 03 2014.
RESULTS: Mean patient age was 49.32±11.82 years, and 71% were women. About half of the participants successfully quit smoking (n=125, 51%). Higher levels of nicotine dependence were associated with lower levels of smoking cessation. There was a notable decrease in the probability of remaining smoking throughout the first month of treatment. After 3 weeks of treatment, only 19% had not quit smoking. The probability of quitting smoking decreases by 2% for every additional year of age.
CONCLUSION: There is a need to revise and expand current strategies to make them more effective in preventing smoking since childhood.

Descriptors: National Program for Tobacco Control; smoking; smoking cessation; tobacco; tobacco use cessation products

12 - Bipolar disorder prevalence: a systematic review and meta-analysis of the literature
Adauto S. Clemente; Breno S. Diniz; Rodrigo Nicolato; Flavio P. Kapczinski; Jair C. Soares; Josélia O. Firmo; Érico Castro-Costa
Pages: 155 - 161

OBJECTIVE: Bipolar disorder (BD) is common in clinical psychiatric practice, and several studies have estimated its prevalence to range from 0.5 to 5% in community-based samples. However, no systematic review and meta-analysis of the prevalence of BD type 1 and type 2 has been published in the literature. We carried out a systematic review and meta-analysis of the lifetime and 1-year prevalence of BD type 1 and type 2 and assessed whether the prevalence of BD changed according to the diagnostic criteria adopted (DSM-III, DSM-III-R vs. DSM-IV).
METHODS: We searched MEDLINE, Scopus, Web of Science, PsycINFO, and the reference lists of identified studies. The analyses included 25 population- or community-based studies and 276,221 participants.
RESULTS: The pooled lifetime prevalence of BD type 1 was 1.06% (95% confidence interval [95%CI] 0.81-1.31) and that of BD type 2 was 1.57% (95%CI 1.15-1.99). The pooled 1-year prevalence was 0.71% (95%CI 0.56-0.86) for BD type 1 and 0.50% (95%CI 0.35-0.64) for BD type 2. Subgroup analysis showed a significantly higher lifetime prevalence of BD type 1 according to the DSM-IV criteria compared to the DSM-III and DSM-IIIR criteria (p < 0.001).
CONCLUSION: This meta-analysis confirms that estimates of BD type 1 and type 2 prevalence are low in the general population. The increase in prevalence from DSM-III and DSM-III-R to DSM-IV may reflect different factors, such as minor changes in diagnostic operationalization, use of different assessment instruments, or even a genuine increase in the prevalence of BD.

Descriptors: Bipolar disorder; prevalence; meta-analysis; DSM-III; DSM-III-R; DSM-IV

13 - Personality disorders in euthymic bipolar patients: a systematic review
Severino Bezerra-Filho; Amanda Galvão-de Almeida; Paula Studart; Marlos V. Rocha; Frederico L. Lopes; Ângela Miranda-Scippa
Pages: 162 - 167

OBJECTIVE: To identify, by means of a systematic review, the frequency with which comorbid personality disorders (PDs) have been assessed in studies of euthymic bipolar patients.
METHODS: PubMed, SciELO and PsychlNFO databases were searched for eligible articles published between 1997 and 2013. After screening 1,249 empirical papers, two independent reviewers identified three articles evaluating the frequency of PDs in patients with bipolar disorders assessed in a state of euthymia.
RESULTS: The total sample comprised 376 euthymic bipolar patients, of whom 155 (41.2%) had at least one comorbid PD. Among them, we found 87 (23.1%) in cluster B, 55 (14.6%) in cluster C, and 25 (6.6%) in cluster A. The frequencies of PD subtypes were: borderline, 38 (10.1%); histrionic, 29 (7.7%); obsessive-compulsive, 28 (7.4%); dependent, 19 (5%); narcissistic, 17 (4.5%); schizoid, schizotypal, and avoidant, 11 patients each (2.95%); paranoid, five (1.3%); and antisocial, three (0.79%).
CONCLUSION: The frequency of comorbid PD was high across the spectrum of euthymic bipolar patients. ln this population, the most common PDs were those in cluster B, and the most frequent PD subtype was borderline, followed by histrionic and obsessive-compulsive.

Descriptors: Bipolar disorder; affective disorder; mood disorder; personality disorders; comorbidity

14 - Determinants of adherence to treatment in first-episode psychosis: a comprehensive review
Emilie Leclerc; Cristiano Noto; Rodrigo A. Bressan; Elisa Brietzke
Pages: 168 - 176

OBJECTIVE: To conduct a comprehensive review of current evidence on factors for nonadherence to treatment in individuals with first-episode psychosis (FEP).
METHODS: MEDLINE, LILACS, PsyclNFO, and SciELO databases were searched with the keywords first episode psychosis, factor, adherence, nonadherence, engagement, disengagement, compliance, and intervention. References of selected studies were consulted for relevant articles.
RESULTS: A total of 157 articles were screened, of which 33 articles were retained for full review. The factors related to nonadherence were: a) patient-related (e.g., lower education level, persistent substance use, forensic history, unemployment, history of physical abuse); b) environment-related (e.g., no family involved in treatment, social adjustment difficulties); c) medication-related (e.g., rapid remission of negative symptoms when starting treatment, therapeutic alliance); and d) illness-related (e.g., more positive symptoms, more relapses). Treatment factors that improve adherence include a good therapeutic alliance and a voluntary first admission when hospitalization occurs.
CONCLUSION: The results of this review suggest that nonadherence to treatment in FEP is multifactorial. Many of these factors are modifiable and can be specifically targeted in early intervention programs. Very few studies have assessed strategies to raise adherence in FEP.

Descriptors: Medication adherence; patient dropouts; risk factors; schizophrenia; bipolar disorder

15 - Impulsive aggression in Brazil: losing opportunities to intervene
Gustavo C. Medeiros; Eric Leppink; Liliana Seger; Ana M. Costa; Carolina Bernardo; Hermano Tavares
Pages: 177 - 178


16 - Prevalence of psychiatric disorders among children and adolescents from four Brazilian regions
Cristiane S. Paula; Evandro S. Coutinho; Jair J. Mari; Luis A. Rohde; Euripedes C. Miguel; Isabel A. Bordin
Pages: 178 - 179


17 - Psychotic syndrome secondary to meningioma treated with a low dose of olanzapine
Joao P. Maia-de-Oliveira; Lizie E. Brasileiro; Carlos E. Correia; João P. Machado-de-Sousa; Jaime E. Hallak
Pages: 179 - 180


18 - Sexual abuse and suicide attempt in bipolar type I patients
Dante G. Duarte; Maila de C. Neves; Maicon R. Albuquerque; Fernando S. Neves; Humberto Corrêa
Pages: 180 - 182