Efectividad del tratamiento farmacológico de la agresividad en pacientes con trastorno límite de la personalidad. Revisión sistemática

Introducción: el Trastorno Límite de la Personalidad afecta del 2% al 6% de los adultos en Estados Unidos. Es una condición de alta relevancia dentro de las patologías psiquiátricas debido a características como impulsividad, inestabilidad en las relaciones interpersonales, disregulación en el estado de ánimo y comportamiento agresivo. Esto determina un impacto negativo en la funcionalidad del individuo siendo la agresividad contra sí mismo o contra otras personas uno de sus componentes claves. Métodos: Revisión sistemática de la literatura de artículos de bases de datos y búsqueda manual de revistas relacionadas que aportaran la mejor evidencia con el fin de encontrar estudios que evaluaran, con instrumentos objetivos, los tratamientos farmacológicos disponibles para el manejo de la agresividad en el TLP .Se evaluó calidad metodológica y los estudios se organizaron en tablas de evidencia. Resultados: La búsqueda arrojo 1081 artículos de los cuales se seleccionaron 52 como potenciales y cinco fueron incluidos en esta revisión. Se clasificaron como nivel de evidencia Ib. El topiramato, el aripiprazol, el divalproato y la fluoxetina mostraron mejores resultados que el placebo especialmente en agresividad e impulsividad. El topiramato fue asociado con pérdida de peso. Los medicamentos fueron seguros y bien tolerados. Discusión: Los medicamentos evaluados mostraron ser mejores que placebo. La diversidad en las escalas utilizadas genera complejidad en la interpretación de resultados. Conclusión: La evidencia sugiere que el tratamiento farmacológico es efectivo en síntomas como agresividad e impulsividad comparado con placebo. Deben considerarse estudios que evalúen combinaciones de fármacos y psicoterapia.

Factores de riesgo de suicidio en mujeres con cáncer de mama

El cáncer de mama es uno de los diagnósticos oncológicos más frecuentes y con altas tasas de mortalidad en mujeres a nivel mundial, en específico con mayor incidencia en países del este de Europa, Asia y Latinoamérica. Su impacto trasciende el aspecto físico y afectando igualmente el área social y psicológica de estas mujeres, generando estados afectivos disfuncionales (depresión, ansiedad, estrés postraumático, conductas suicidas) que afectan su calidad de vida. La literatura reporta que el suicidio en pacientes con cáncer es 2 veces mayor que en la población general, reconociendo dentro de los grupos vulnerables a los pacientes con cáncer de mama. Objetivo: realizar una revisión de la literatura científica producida entre 2002 – 2012, sobre los factores de riesgo de suicidio en mujeres con cáncer de mama. Método: se revisaron 121 artículos científicos obtenidos en bases de datos especializadas. Resultados: En efecto, estas mujeres tienen factores de riesgo para el suicidio (raza, comorbilidad médica y psiquiátrica, miedo a la recidiva, estadios avanzados de la enfermedad, alteraciones en la imagen corporal, cambios en el rol social y efectos secundarios de los tratamientos oncológicos). Conclusiones: durante el curso de la enfermedad se presentan diversos factores biopsicosociales que pueden conducir a la ideación o a la intención suicida. Por lo anterior, es necesario incorporar en la atención psicológica de las mujeres con cáncer de mama la evaluación y la intervención de la conducta suicida y continuar profundizando en el estudio de este fenómeno cuyos efectos son deletéreos para el bienestar del paciente oncológico.

Calidad de vida en personas con hemofilia: una revisión de la literatura

Introducción: La hemofilia es una enfermedad poco frecuente; no obstante, los avances en los tratamientos de pacientes hemofílicos en las últimas décadas han generado cambios en su calidad de vida. Esto ha motivado el desarrollo de múltiples investigaciones al respecto. Objetivo: Revisar la literatura sobre la calidad de vida en el paciente hemofílico, producida en el periodo 2008-2012. Método: Se consultaron algunas bases de datos científicas utilizando como palabras clave “hemofilia” y “calidad de vida”. Se recopiló la información encontrada y se organizó según los objetivos propuestos en “factores negativos” y “factores protectores” de la calidad de vida a nivel fisiológico, psicosocial y cultural; “instrumentos para la evaluación de la calidad de vida” a nivel específico y general; y antecedentes empíricos de los últimos cinco años en los que se evaluara la calidad de vida o se realizara alguna intervención en la misma. Resultados: En general la información disponible sobre el comportamiento epidemiológico de la hemofilia es limitada. El interés por factores protectores y negativos es principalmente de tipo fisiológico, aunque se encontraron factores de tipo psicosocial y cultural, lo que indica la importancia de profundizar en esta temática. Existen pocos instrumentos especializados para la evaluación de la calidad de vida en hemofílicos. La evidencia empírica se centra en la evaluación. Conclusión: El estudio de la calidad de vida en pacientes hemofílicos amerita ser abordado de manera interdisciplinaria.

Diseño de un modelo de intervención del suicidio en niños y adolescentes

Resumen El objetivo de este estudio fue el de diseñar un modelo de intervención para la prevención del suicidio en la población escolar de niños y adolescentes, con 72 participantes de un colegio público y un colegio privado de la ciudad de Bogotá. Se caracterizó el suicidio en la ciudad de Bogotá en los últimos nueve años, los aspectos legales, se analizaron algunos modelos de prevención, se identificaron los principales factores de riesgo y factores protectores y se propusieron estrategias para su prevención. Este modelo está basado en la administración social del riesgo y los factores protectores y de riesgo, susceptibles de modificación. Se realizó una prueba de tamizaje y fueron utilizados: el Inventario de depresión infantil (CDI de Kovacs), la escala de desesperanza de Beck y la escala de ansiedad para niños y adolescentes de Spence, validadas a nivel internacional. Se observó una correlación positiva (0.490) mediante el coeficiente de rangos de Spearman, con una significación de 0,01 (bilateral) para los tres factores de riesgo. Se hace entrega de un manual de instrucción para la intervención temprana del suicidio en esta población y un folleto informativo dirigido a padres de familia sobre los factores de riesgo y factores protectores. A partir de esto se plantean implicaciones futuras.

Apoyo social e ideación suicida en pacientes con cáncer

El diagnóstico de cáncer ha sido asociado con un alto riesgo de presentar ideación suicida en comparación con la población no oncológica, sin embargo se ha considerado al apoyo social como un factor protector para la ocurrencia de esta conducta. La presente investigación tuvo como objetivo identificar la relación entre el apoyo social percibido y la ideación suicida en 90 pacientes oncológicos adultos en Bogotá, bajo la hipótesis de que a mayor apoyo social percibido, menor presencia de ideación suicida. Se midió la variable de apoyo social a través del cuestionario Duke UNC y la ideación suicida a través de cuatro instrumentos: Escala de Ideación Suicida (SSI), Escala de Desesperanza de Beck (BHS), el ítem 9 del Inventario de Depresión de Beck (BDI-IA) y una entrevista semiestructurada. Los resultados mostraron que no existe relación entre el apoyo social percibido y la ideación suicida. Por otro lado se identificó una prevalencia de suicidio entre 5,6% y 22,77%, confirmando que el paciente con cáncer considera el suicidio y es fundamental evaluar esta variable en esta población. Se considera importante continuar con la realización de investigaciones que permitan generalizar los resultados a la población oncológica colombiana.

Pubertal stage and deliberate self-harm in adolescents

Objective: To ascertain the association between pubertal stage and deliberate self-harm.

Method: Cross-sectional survey of 12- to 15-year-olds in 300 secondary schools in the U.S. state of Washington in February-April 2002 and the Australian state of Victoria in June-August 2002. A total of 3,332 students in grades 7 and 9 provided complete data on episodes of deliberate self-harm in the previous 12 months and pubertal stage. Pubertal stage was assessed with the Pubertal Development Scale.

Results: The prevalence of deliberate self-harm was 3.7% with a more than twofold higher rate in females. Late puberty was associated with a more than fourfold higher rate of self-harm (odds ratio 4.6, 95% confidence interval 1.5-14) after adjustment for age and school grade level. In contrast age had a protective association (odds ratio 0.7, confidence interval 0.4-1.0). The sharpest rises in prevalence across puberty were for self-laceration and self-poisoning in females. Higher rates of depressive symptoms, frequent alcohol use, and initiation of sexual activity largely accounted for the association between self-harm and pubertal stage in multivariate models.

Conclusions: Puberty is associated with changes in the form and frequency of self-harm. For adolescents with a gap between puberty and brain development, risk factors such as early sexual activity and substance abuse may be particularly potent.

Longitudinal evaluation of a risk-factor model for adolescent suicidality

This research developed two best-fitting structural equation models of risk factors for adolescent depression and suicidality: a core model, which included parenting factors, gender, depression, and suicidality, and an extended model, which also encompassed personality traits (Introversion and Impulsivity) and mood factors (Anxiety and Anger). Further, this research investigated the consistency of model fit across time (Le., 1 month & 12 months) and samples, and explored the effectiveness of the ReachOut! Internet site as a psychoeducational prevention strategy for adolescent depression and suicidality. Gender, age, and location differences were also explored. Participants were 185 Year-9 students and 93 Year-10 students aged 14 - 16 years, from seven secondary schools in regional and rural Victoria. Students were given a survey which included the Parental Bonding Instrument (Parker, Tupling, & Brown, 1979), the Millon Adolescent Personality Inventory (Millon, Green, & Meagher, 1982), the Profile of Mood States Inventory (McNair & Lorr, 1964), items on suicidal behaviour including some questions from the Revised Adolescent Suicide Questionnaire (Pearce & Martin, 1994), and questions on loss and general demographics. Results supported an indirect model of risk factors, with family factors directly influencing personality factors, which in turn influenced mood factors, including depression, which then influenced suicidality. At the theoretical level, results supported Attachment Theory (Bowlby, 1969), demonstrating that perceived parenting styles that are warm and not overly controlling are more conducive to an adolescent's emotional well-being than are parenting styles that are cold and controlling. Further, results supported Millon's theory of personality (1981), demonstrating that parenting style influences a child's personality. Short-term intervention effects from the internet site were a decrease in Introversion for the full sample, and decreased Inhibition and Suicidality for a high-risk subgroup. Long-term age effects were decreased Inhibition and increased Anxiety for the fall sample. There was also a probable intervention effect for Depression for the high-risk subgroup. No location differences for the risk factors were found between regional and rural areas.

Legal bans on pro-suicide web sites : an early retrospective from Australia

There are worldwide concerns that pro-suicide web sites may trigger suicidal behaviors among vulnerable individuals. In 2006, Australia became the first country to criminalize such sites, sparking heated debate. Concerns were expressed that the law casts the criminal net too widely; inappropriately interferes with the autonomy of those who wish to die; and has jurisdictional limitations, with off-shore web sites remaining largely immune. Conversely, proponents point out that the law may limit access to domestic pro-suicide web sites, raise awareness of Internet-related suicide, mobilize community efforts to combat it, and serve as a powerful expression of societal norms about the promotion of suicidal behavior.

Genetic polymorphisms in glutathione-S-transferases are associated with anxiety and mood disorders in nicotine dependence

Nicotine dependence is associated with an increased risk of mood and anxiety disorders and suicide. The primary hypothesis of this study was to identify whether the polymorphisms of two glutathione-S-transferase enzymes (GSTM1 and GSTT1 genes) predict an increased risk of mood and anxiety disorders in smokers with nicotine dependence.

STin2 VNTR polymorphism is associated with comorbid tobacco use and mood disorders.

There is a significant comorbidity between mood disorders and tobacco use disorder (TUD), which may be related to both genetic and environmental factors. Gene variants of the 5-HT transporter, such as STin2 VNTR (a variable number of tandem repeats in the functional serotonin transporter intron 2) may be associated with mood disorders and TUD.

Tobacco use in bipolar disorder

Tobacco use in mental health in general and bipolar disorder in particular remains disproportionally common, despite declining smoking rates in the community. Furthermore, interactions between tobacco use and mental health have been shown, indicating the outcomes for those with mental health disorders are impacted by tobacco use. Factors need to be explored and addressed to improve outcomes for those with these disorders and target specific interventions for people with psychiatric illness to cease tobacco smoking. In the context of bipolar disorder, this review explores; the effects of tobacco smoking on symptoms, quality of life, suicidal behavior, the biological interactions between tobacco use and bipolar disorder, the interactions between tobacco smoking and psychiatric medications, rates and factors surrounding tobacco smoking cessation in bipolar disorder and suggests potential directions for research and clinical translation. The importance of this review is to bring together the current understanding of tobacco use in bipolar disorder to highlight the need for specific intervention.

Learning vector representation of medical objects via EMR-driven nonnegative restricted Boltzmann machines (eNRBM)

Electronic medical record (EMR) offers promises for novel analytics. However, manual feature engineering from EMR is labor intensive because EMR is complex - it contains temporal, mixed-type and multimodal data packed in irregular episodes. We present a computational framework to harness EMR with minimal human supervision via restricted Boltzmann machine (RBM). The framework derives a new representation of medical objects by embedding them in a low-dimensional vector space. This new representation facilitates algebraic and statistical manipulations such as projection onto 2D plane (thereby offering intuitive visualization), object grouping (hence enabling automated phenotyping), and risk stratification. To enhance model interpretability, we introduced two constraints into model parameters: (a) nonnegative coefficients, and (b) structural smoothness. These result in a novel model called eNRBM (EMR-driven nonnegative RBM). We demonstrate the capability of the eNRBM on a cohort of 7578 mental health patients under suicide risk assessment. The derived representation not only shows clinically meaningful feature grouping but also facilitates short-term risk stratification. The F-scores, 0.21 for moderate-risk and 0.36 for high-risk, are significantly higher than those obtained by clinicians and competitive with the results obtained by support vector machines.

Obsessive-compulsive disorder: Prevalence, comorbidity, impact, and help-seeking in the British National Psychiatric Morbidity Survey of 2000

Objective: There is little information about obsessive-compulsive disorder in large representative community samples. The authors aimed to establish obsessive-compulsive disorder prevalence and its clinical typology among adults in private households in Great Britain and to obtain generalizable estimates of impairment and help-seeking.Method: Data from the British National Psychiatric Morbidity Survey of 2000, comprising 8,580 individuals, were analyzed using appropriate measurements. The study compared individuals with obsessive-compulsive disorder, individuals with other neurotic disorders, and a nonneurotic comparison group. ICD-10 diagnoses were derived from the Clinical Interview Schedule-Revised.Results: the authors identified 114 individuals (74 women, 40 men) with obsessive-compulsive disorder, with a weighted 1-month prevalence of 1.1%. Most individuals (55%) in the obsessive-compulsive group had obsessions only. Comorbidity occurred in 62% of these individuals, which was significantly greater than the group with other neuroses (10%). Co-occurring neuroses were depressive episode (37%), generalized anxiety disorder (31%), agoraphobia or panic disorder (22%), social phobia (17%), and specific phobia (15%). Alcohol dependence was present in 20% of participants, mainly men, and drug dependence was present in 13%. Obsessive-compulsive disorder, compared with other neurotic disorders, was associated with more marked social and occupational impairment. One-quarter of obsessive-compulsive disorder participants had previously attempted suicide. Individuals with pure and comorbid obsessive-compulsive disorder did not differ according to most indices of impairment, including suicidal behavior, but pure individuals were significantly less likely to have sought help (14% versus 56%).Conclusions: A rare yet severe mental disorder, obsessive-compulsive disorder is an atypical neurosis, of which the public health significance has been underestimated. Unmet need among individuals with pure obsessive-compulsive disorder is a cause for concern, requiring further investigation of barriers to care and interventions to encourage help-seeking.

Prevention of mental ill-health and suicide: Public health perspectives

According to the World Health Organization (WHO) estimates for the year 2020, approximately 1.5 million people will commit suicide, and at least 10 times that many will make an attempt. This paper offers a brief overview of the current state of the epidemiology of suicide, a burgeoning public health problem. The information provided is based in large measure on reports of suicide mortality from 130/193 countries. In order to contextualize these data, this paper explores the contribution of both individual and sociocultural factors that influence suicidal behavior, from which much has been learned. Outlining the history of attempts by international and national organizations like WHO, United Nations, member states in the European community and other countries to regularize identification and suicide reporting procedures, this paper also demonstrates that serious knowledge gaps remain. Minimal requirements for successful evidence-based interventions are presented. (C) 2010 Published by Elsevier Masson SAS.