Psychiatric disorders and psychiatric consultation in a general hospital: A case- control study

Introduction: Psychiatric consultation (PC) has been considered an efficient tool to develop research, to track and to give assistance benefiting patients, health professionals and the institution. However, it has not been much used in Brazil. Although 30 to 50% of general hospital (GH) inpatients may present a psychiatric disorder, only 1 to 12% of them are referred to assessment. The aims of this study were: to assess mental disorders in a GH; to identify which of these patients are sent to psychiatric care; to verify alleged reasons for referral to psychiatric consultation, and to examine the relationship between PC and psychiatric learning (during medical school and residence). Methods: A case-control patient study was conducted (47 cases and 94 controls) to analyze in detail the following variables: socio-demographic; clinical; degree of information (about the disease and diagnostic/therapeutic procedures), and relationship between patient and health team. Psychiatric diagnoses were made according to the ICD- 10 criteria. The Self Report Questionnaire (SRQ), the CAGE and Brief Psychiatric Rating Scale (BPRS) were used as well as a specifically designed questionnaire to collect clinical and demographic data. Results: Behavioral alterations, either of elation or of depression, were the main for requesting a PC; 95.8% of the cases and 27.7% of the controls had a mental disorder. Organic mental disorders and alcohol-related disorders were the most frequent diagnoses in group I (cases), while anxiety, depressive and alcohol-related disorders were predominant in group II (controls). Control group patients were better informed and more able to establish an appropriate relationship with the health team than case patients. The logistic regression showed CAGE-positive patients having 12.85 times greater risk of being referred to PC, followed by unemployed patients (2.44 times more PC referrals). Discussion: The SRQ and CAGE were quite useful in the screening of possible patients and might be important for medical students to learn and use as generalists. Further research is needed to verify if and how the newly-established service will improve the diagnostic and treatment skills of our students.

Juvenile myoclonic epilepsy: The impact of clinical variables and psychiatric disorders on executive profile assessed with a comprehensive neuropsychological battery

Executive dysfunction is reported in juvenile myoclonic epilepsy (JME). However, batteries employed in previous studies included no more than three tests of executive function. In this study, we aimed to assess executive and attentional functions in JME using a comprehensive battery of eight tests (encompassing fifteen subtests). We also evaluated neuropsychological profiles using a clinical criterion of severity and correlated these findings with epilepsy clinical variables and the presence of psychiatric disorders. We prospectively evaluated 42 patients with JME and a matched control group with Digit Span tests (forward and backward), Stroop Color-Word Test, Trail Making Test, Wisconsin Card-Sorting Test, Matching Familiar Figures Test and Word Fluency Test. We estimated IQ with the Matrix Reasoning and Vocabulary subtests of the Wechsler Abbreviated Intelligence Scale. The patients with JME showed specific deficits in working memory, inhibitory control, concept formation, goal maintenance, mental flexibility, and verbal fluency. We observed attentional deficits in processes such as alertness and attention span and those requiring sustained and divided attention. We found that 83.33% of the patients had moderate or severe executive dysfunction. In addition, attentional and executive impairment was correlated with higher frequency of seizures and the presence of psychiatric disorders. Furthermore, executive dysfunction correlated with a longer duration of epilepsy. Our findings indicate the need for comprehensive neuropsychological batteries in patients with JME, in order to provide a more extensive evaluation of attentional and executive functions and to show that some relevant deficits have been overlooked. (C) 2012 Elsevier Inc. All rights reserved.

Attitudes of mental health professionals towards persons with schizophrenia: a transcultural comparison between Switzerland and Brazil

Background: Stigmatization is an important issue in the treatment and course of schizophrenia. The maintenance of stigmatizing attitudes may be related to socio-cultural factors. Objectives: To compare stigmatizing attitudes of mental health professionals in the culturally diverse countries Brazil and Switzerland. Methods: We analyzed data of two broad stigmatization surveys from Switzerland and Brazil by focusing on the social distance and attitudes of mental health professionals towards the acceptance of side effects of psychopharmacological treatment. Results: Swiss mental health professionals showed significantly higher levels of social distance than their Brazilian counterparts. There was also a weak effect of age as well as an interaction effect between origin and age. With respect to the acceptance of side effects, the effect of origin was rather weak. With the exception of drug dependence, Swiss professionals' acceptance of long-lasting side effects was significantly higher than for their counterparts in Brazil. Discussion: The strong association between origin and social distance may be related to the socio-cultural background of the mental health professionals. In comparison with Switzerland, Brazil is very heterogeneous in terms of ethnicity and socio-economic structure. The distinct acceptance of side effects may additionally be related to the more sophisticated medicaments (i.e. new generation of antipsychotic drugs) commonly used in Switzerland. Hengartner MP, et al. / Rev Psiq Clin. 2012;39(4):115-21

Stigma and higher rates of psychiatric re-hospitalization: Sao Paulo public mental health system

Objective: The aim of this study was to assess re-hospitalization rates of individuals with psychosis and bipolar disorder and to study determinants of readmission. Methods: Prospective observational study, conducted in Sao Paulo, Brazil. One hundred-sixty-nine individuals with bipolar and psychotic disorder in need of hospitalization in the public mental health system were followed for 12 months after discharge. Their families were contacted by telephone and interviews were conducted at 1, 2, 6 and 12 months post-discharge to evaluate readmission rates and factors related. Results: One-year re-hospitalization rate was of 42.6%. Physical restraint during hospital stay was a risk factor (OR = 5.4-10.5) for readmission in most models. Not attending consultations after discharge was related to the 12-month point readmission (OR = 8.5, 95% CI 2.3-31.2) and to the survival model (OR = 3.2, 95% CI 1.5-7.2). Number of previous admissions was a risk factor for the survival model (OR = 6.6-11.9). Family's agreement with permanent hospitalization of individuals with mental illness was the predictor associated to readmission in all models (OR = 3.5-10.9) and resulted in shorter survival time to readmission; those readmitted were stereotyped as dangerous and unhealthy. Conclusions: Family's stigma towards mental illness might contribute to the increase in readmission rates of their relatives with psychiatric disorders. More studies should be conducted to depict mechanisms by which stigma increases re-hospitalization rates.

Teachers' sick leave due to mental and behavioral disorders and return to work

This manuscript presents a review of the literature about medical leaves due to mental and behavioral disorders and return to work of teachers. There are scarce published manuscripts. Most articles relate with prevalence of mental disorders and factors associated with the work organization, and did not mention intervention proposals and or changes in the work organization and teaching work. Proposed actions are discussed.

Stigma and higher rates of psychiatric re-hospitalization: São Paulo public mental health system

OBJECTIVE: The aim of this study was to assess re-hospitalization rates of individuals with psychosis and bipolar disorder and to study determinants of readmission. METHODS: Prospective observational study, conducted in São Paulo, Brazil. One hundred-sixty-nine individuals with bipolar and psychotic disorder in need of hospitalization in the public mental health system were followed for 12 months after discharge. Their families were contacted by telephone and interviews were conducted at 1, 2, 6 and 12 months post-discharge to evaluate readmission rates and factors related. RESULTSOne-year re-hospitalization rate was of 42.6%. Physical restraint during hospital stay was a risk factor (OR = 5.4-10.5) for readmission in most models. Not attending consultations after discharge was related to the 12-month point readmission (OR = 8.5, 95%CI 2.3-31.2) and to the survival model (OR = 3.2, 95%CI 1.5-7.2). Number of previous admissions was a risk factor for the survival model (OR = 6.6-11.9). Family's agreement with permanent hospitalization of individuals with mental illness was the predictor associated to readmission in all models (OR = 3.5-10.9) and resulted in shorter survival time to readmission; those readmitted were stereotyped as dangerous and unhealthy. CONCLUSIONS: Family's stigma towards mental illness might contribute to the increase in readmission rates of their relatives with psychiatric disorders. More studies should be conducted to depict mechanisms by which stigma increases re-hospitalization rates.

Pathogenesis and classification of eosinophil disorders: a review of recent developments in the field

Eosinophils and their products play an essential role in the pathogenesis of various reactive and neoplastic disorders. Depending on the underlying disease, molecular defect and involved cytokines, hypereosinophilia may develop and may lead to organ damage. In other patients, persistent eosinophilia is accompanied by typical clinical findings, but the causative role and impact of eosinophilia remain uncertain. For patients with eosinophil-mediated organ pathology, early therapeutic intervention with agents reducing eosinophil counts can be effective in limiting or preventing irreversible organ damage. Therefore, it is important to approach eosinophil disorders and related syndromes early by using established criteria, to perform all appropriate staging investigations, and to search for molecular targets of therapy. In this article, we review current concepts in the pathogenesis and evolution of eosinophilia and eosinophil-related organ damage in neoplastic and non-neoplastic conditions. In addition, we discuss classifications of eosinophil disorders and related syndromes as well as diagnostic algorithms and standard treatment for various eosinophil-related disorders.

[Implementation of a routine gradual psycho-diagnostic programme in somatic rehabilitation centres - results of a pilot study]

STUDY AIM: A pilot study was conducted to implement and evaluate a routine gradual psycho-diagnostic programme to improve diagnostics and treatment of mental disorders in somatic rehabilitation centres. First of all, implementation strategies were acquired in trainings together with psychologists and physicians. The psycho-diagnostic programme consists of a screening instrument (PHQ-9) designed to permit time-effective detection of comorbid mental disorders. Besides evaluation of the training, the aim of the study was to analyze the extent to which it is possible to implement the routine gradual psycho-diagnostic programme in practice. Additionally, it was intended to identify beneficial and obstructive conditions for implementation. METHODOLOGY: The pilot study was conducted in two orthopaedic and one cardiological rehabilitation centre. The training was evaluated directly after its completion using a questionnaire. Three months after its implementation, the introduction of the psycho-diagnostic programme was evaluated using interviews with n=11 physicians and psychologists. RESULTS: The training was rated positively by the participants . Implementation of the entire gradual psycho-diagnostic programme was possible in one centre and to some degree in the other two. Beneficial for implementation were a frank organisational climate, sufficient time resources, and physicians' biopsychosocial understanding of disease. A dismissive attitude towards psycho-diagnostics, little communication between staff members, little perceived advantage for one's own work and fear to stigmatise patients by psychiatric diagnoses were obstructive. CONCLUSION: Essential for a successful implementation are sufficient time and personal resources, a motivation for change in staff and centre management, and a positive attitude regarding psycho-diagnostics in clinic staff. Furthermore, flexibility in implementation strategies and the opportunity to participate in the implementation process are important.

BCOR analysis in patients with OFCD and Lenz microphthalmia syndromes, mental retardation with ocular anomalies, and cardiac laterality defects

Oculofaciocardiodental (OFCD) and Lenz microphthalmia syndromes form part of a spectrum of X-linked microphthalmia disorders characterized by ocular, dental, cardiac and skeletal anomalies and mental retardation. The two syndromes are allelic, caused by mutations in the BCL-6 corepressor gene (BCOR). To extend the series of phenotypes associated with pathogenic mutations in BCOR, we sequenced the BCOR gene in patients with (1) OFCD syndrome, (2) putative X-linked ('Lenz') microphthalmia syndrome, (3) isolated ocular defects and (4) laterality phenotypes. We present a new cohort of females with OFCD syndrome and null mutations in BCOR, supporting the hypothesis that BCOR is the sole molecular cause of this syndrome. We identify for the first time mosaic BCOR mutations in two females with OFCD syndrome and one apparently asymptomatic female. We present a female diagnosed with isolated ocular defects and identify minor features of OFCD syndrome, suggesting that OFCD syndrome may be mild and underdiagnosed. We have sequenced a cohort of males diagnosed with putative X-linked microphthalmia and found a mutation, p.P85L, in a single case, suggesting that BCOR mutations are not a major cause of X-linked microphthalmia in males. The absence of BCOR mutations in a panel of patients with non-specific laterality defects suggests that mutations in BCOR are not a major cause of isolated heart and laterality defects. Phenotypic analysis of OFCD and Lenz microphthalmia syndromes shows that in addition to the standard diagnostic criteria of congenital cataract, microphthalmia and radiculomegaly, patients should be examined for skeletal defects, particularly radioulnar synostosis, and cardiac/laterality defects.

Statistical characterization and development of summary measures of non-normal distributions of nuclear morphometry data from prostate cancer cells for use as prognostic indicators

Nuclear morphometry (NM) uses image analysis to measure features of the cell nucleus which are classified as: bulk properties, shape or form, and DNA distribution. Studies have used these measurements as diagnostic and prognostic indicators of disease with inconclusive results. The distributional properties of these variables have not been systematically investigated although much of the medical data exhibit nonnormal distributions. Measurements are done on several hundred cells per patient so summary measurements reflecting the underlying distribution are needed.^ Distributional characteristics of 34 NM variables from prostate cancer cells were investigated using graphical and analytical techniques. Cells per sample ranged from 52 to 458. A small sample of patients with benign prostatic hyperplasia (BPH), representing non-cancer cells, was used for general comparison with the cancer cells.^ Data transformations such as log, square root and 1/x did not yield normality as measured by the Shapiro-Wilks test for normality. A modulus transformation, used for distributions having abnormal kurtosis values, also did not produce normality.^ Kernel density histograms of the 34 variables exhibited non-normality and 18 variables also exhibited bimodality. A bimodality coefficient was calculated and 3 variables: DNA concentration, shape and elongation, showed the strongest evidence of bimodality and were studied further.^ Two analytical approaches were used to obtain a summary measure for each variable for each patient: cluster analysis to determine significant clusters and a mixture model analysis using a two component model having a Gaussian distribution with equal variances. The mixture component parameters were used to bootstrap the log likelihood ratio to determine the significant number of components, 1 or 2. These summary measures were used as predictors of disease severity in several proportional odds logistic regression models. The disease severity scale had 5 levels and was constructed of 3 components: extracapsulary penetration (ECP), lymph node involvement (LN+) and seminal vesicle involvement (SV+) which represent surrogate measures of prognosis. The summary measures were not strong predictors of disease severity. There was some indication from the mixture model results that there were changes in mean levels and proportions of the components in the lower severity levels. ^

The role of metabotropic glutamate receptor 5 in the pathogenesis of mood disorders and addiction: combining preclinical evidence with human Positron Emission Tomography (PET) studies.

In the present review, we deliver an overview of the involvement of metabotropic glutamate receptor 5 (mGluR5) activity and density in pathological anxiety, mood disorders and addiction. Specifically, we will describe mGluR5 studies in humans that employed Positron Emission Tomography (PET) and combined the findings with preclinical animal research. This combined view of different methodological approaches-from basic neurobiological approaches to human studies-might give a more comprehensive and clinically relevant view of mGluR5 function in mental health than the view on preclinical data alone. We will also review the current research data on mGluR5 along the Research Domain Criteria (RDoC). Firstly, we found evidence of abnormal glutamate activity related to the positive and negative valence systems, which would suggest that antagonistic mGluR5 intervention has prominent anti-addictive, anti-depressive and anxiolytic effects. Secondly, there is evidence that mGluR5 plays an important role in systems for social functioning and the response to social stress. Finally, mGluR5's important role in sleep homeostasis suggests that this glutamate receptor may play an important role in RDoC's arousal and modulatory systems domain. Glutamate was previously mostly investigated in non-human studies, however initial human clinical PET research now also supports the hypothesis that, by mediating brain excitability, neuroplasticity and social cognition, abnormal metabotropic glutamate activity might predispose individuals to a broad range of psychiatric problems.

A full pedigree based method for the statistical assessment of genetic anticipation

Genetic anticipation is defined as a decrease in age of onset or increase in severity as the disorder is transmitted through subsequent generations. Anticipation has been noted in the literature for over a century. Recently, anticipation in several diseases including Huntington's Disease, Myotonic Dystrophy and Fragile X Syndrome were shown to be caused by expansion of triplet repeats. Anticipation effects have also been observed in numerous mental disorders (e.g. Schizophrenia, Bipolar Disorder), cancers (Li-Fraumeni Syndrome, Leukemia) and other complex diseases. ^ Several statistical methods have been applied to determine whether anticipation is a true phenomenon in a particular disorder, including standard statistical tests and newly developed affected parent/affected child pair methods. These methods have been shown to be inappropriate for assessing anticipation for a variety of reasons, including familial correlation and low power. Therefore, we have developed family-based likelihood modeling approaches to model the underlying transmission of the disease gene and penetrance function and hence detect anticipation. These methods can be applied in extended families, thus improving the power to detect anticipation compared with existing methods based only upon parents and children. The first method we have proposed is based on the regressive logistic hazard model. This approach models anticipation by a generational covariate. The second method allows alleles to mutate as they are transmitted from parents to offspring and is appropriate for modeling the known triplet repeat diseases in which the disease alleles can become more deleterious as they are transmitted across generations. ^ To evaluate the new methods, we performed extensive simulation studies for data simulated under different conditions to evaluate the effectiveness of the algorithms to detect genetic anticipation. Results from analysis by the first method yielded empirical power greater than 87% based on the 5% type I error critical value identified in each simulation depending on the method of data generation and current age criteria. Analysis by the second method was not possible due to the current formulation of the software. The application of this method to Huntington's Disease and Li-Fraumeni Syndrome data sets revealed evidence for a generation effect in both cases. ^