Eficacia de la estimulación magnética transcraneal en la disminución de severidad en el trastorno depresivo mayor en monoterapia y coadyuvante comparado con tratamientos farmacológicos. Revisión sistemática y meta-análisis

Resumen Introducción Una posible opción de tratamiento para el manejo del trastorno depresivo mayor (TDM) es la estimulación magnética transcraneal (EMT) que ha mostrado propiedades antidepresivas superiores al placebo con un buen perfil de seguridad. El objetivo del presente trabajo es determinar la reducción en la severidad del TDM y la proporción de eventos adversos (EA) en pacientes con TDM refractario y no refractario, posterior al uso de EMT administrada en monoterapia o tratamiento coadyuvante comparado con terapia farmacológica. Metodología Se planteó una pregunta PICOT de la cual se realizó una búsqueda sistemática de estudios clínicos en las bases de datos Medline, EMBASE y Cochrane. Dos investigadores en forma independiente realizaron la selección de artículos, evaluación de calidad con la herramienta de la colaboración Cochrane y extracción de datos. Se extrajeron datos de eficacia como tasa de respuesta, porcentaje de remisión, calidad de vida, diminución sintomática del trastorno depresivo mayor en la escala de Hamilton y capacidad funcional. Igualmente, proporción de pacientes con EA. Se realizó un meta-análisis de estas variables teniendo en cuenta la heterogeneidad. Resultados La presente revisión sistemática incluyó 26 estudios clínicos aleatorizados de baja calidad metodológica mostrando que la EMT presentó una eficacia superior cuando es usada como coadyuvante a las terapias con que venían siendo tratados los pacientes con TDM refractario y no refractario en los desenlaces de tasa de respuesta y porcentaje de remisión. En el caso de intervenciones farmacológicas específicas, la EMT presento eficacia similar, tanto en terapia coadyuvante como en monoterapia comparado con las intervenciones farmacológicas. En cuanto a seguridad, la EMT presenta un buen perfil de seguridad debido a que en todos los escenarios estudiados los EA fueron no serios y baja frecuencia Conclusiones La evidencia disponible sugiere que la EMT mostró ser efectivo y seguro para el manejo del TDM refractario y no refractario. Sin embargo, la evidencia es débil por lo tanto se necesita mayor investigación clínica que soporte su uso.

The multidimensional measurement of the positive symptoms of psychosis

The measures most frequently used to assess psychotic symptoms fail to reflect important dimensions. The Psychotic Symptom Rating Scale (PSYRATS) aims to capture the multidimensional nature of auditory hallucinations and delusions. Individuals (N = 276) who had recently relapsed with positive symptoms completed the auditory hallucinations and delusions PSYRATS scales. These scores were compared with the relevant items from the SAPS and PANSS, and with measures of current mood. Total scores and distribution of items of the PSYRATS scales are presented and correlated with other measures. Positive symptom items from the SAPS and PANSS reflected the more objective aspects of PSYRATS ratings of auditory hallucinations and delusions (frequency and conviction) but were relatively poor at measuring distress. A major strength of the PSYRATS scales is the specific measurement of the distress dimension of symptoms, which is a key target of psychological intervention. It is advised that the PSYRATS should not be used as a total score alone, whilst further research is needed to clarify the best use of potential subscales. Copyright (c) 2007 John Wiley & Sons, Ltd.

Influence of education and depressive symptoms on cognitive function in the elderly

Objective: The purpose of the present study was to investigate the influence that education and depression have on the performance of elderly people in neuropsychological tests. Methods: The study was conducted at the Institute of Psychiatry, University of Sao Paulo School of Medicine, Hospital das Clinicas. All of the individuals evaluated were aged 60 or older. The study sample consisted of 59 outpatients with depressive disorders and 51 healthy controls. We stratified the sample by level of education: low = 1-4 years of schooling; high = 5 or more years of schooling. Evaluations consisted of psychiatric assessment, cognitive assessment, laboratory tests and cerebral magnetic resonance imaging. Results: We found that level of education influenced all the measures of cognitive domains investigated (intellectual efficiency, processing speed, attention, executive function and memory) except the Digit Span Forward and Fuld Object Memory Evaluation (immediate and delayed recall), whereas depressive symptoms influenced some measures of memory, attention, executive function and processing speed. Although the combination of a low level of education and depression had a significant negative influence on Stroop Test part B, Trail Making Test part B and Logical Memory (immediate recall), we found no other significant effects of the interaction between level of education and depression. Conclusion: The results of this study underscore the importance of considering the level of education in the analysis of cognitive performance in depressed elderly patients, as well as the relevance of developing new cognitive function tests in which level of education has a reduced impact on the results.

Functional capacity of Brazilian patients with Parkinson's disease (PD): Relationship between clinical characteristics and disease severity

Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq)

Cognitive Deficits in Machado-Joseph Disease Correlate with Hypoperfusion of Visual System Areas

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Um transtorno delirante somático atípico

This paper describes the case of a 38 year-old single man with a previous history of social phobia and alcoholism, who presented an unusual pathological belief during the last 9 years. He believe that the muscles of his arms were loose, separated from the bones, and that a green fluid flowed from his shoulders, running under the skin towards his fingers, and returning to the shoulders. He also reported pain, weakness and sensations of loose and fluffy muscles, besides having visual and kinesthetic hallucinations and judgement impairment. No other psychopathological manifestations were observed. There was a worsening of the complaints and depressive symptoms with the use of pimozide and no improvement with fluoxetine, venlafaxine or risperidone. He is presently taking sulpiride. Psychopathological issues and difficulties in diagnosis and treatment are discussed.

Level of insight and clinical features of obsessive-compulsive disorder with and without body dysmorphic disorder

Introduction: Body dysmorphic disorder (BDD) and obsessive-compulsive disorder (OCD) have several similarities and are included among the obsessive-compulsive spectrum of disorders. However, the content of preoccupations and level of insight of BDD patients differ from OCD patients. Objective: To compare the level of insight regarding obsessive-compulsive symptoms (OCS) and other clinical features in OCD patients with and without comorbid BDD. Methods: We evaluated 103 OCD patients (n=25, comorbid BDD), according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria using the Structured Clinical Interview for DSM-IV, the Yale-Brown Obsessive-Compulsive Scale, the University of Sao Paulo Sensory Phenomena Scale, the Beck Depression and Anxiety Inventories, and the Brown Assessment of Beliefs Scale. Resylts: The study groups differed significantly on several clinical features, including level of insight. A worse level of insight regarding OCS was independently associated with the presence of comorbid BDD. Lower educational level, more psychiatric comorbidities, presence of somatic and hoarding obsessions, and presence of intrusive images were associated with BDD comorbidity, even after adjusting for possible confounders. Conclusion: The presence of BDD in OCD patients is associated with poorer insight into obsessional beliefs and higher morbidity, reflected by lower educational levels and higher number of psychiatric comorbid disorders in general.

Síntomas depresivos y trastorno motor en pacientes con enfermedad de Parkinson

Introduction. Complex relations between brain and psychopathology have attracted the interest of researchers, aiming to clarify the neurobiological mechanisms of depression in Parkinson's disease, obviously in addiction to mental features. Aims. The association of motor impairment and decline of personal autonomy with severity of depressive symptoms was the hypothesis of the present study. Aiming to check this hypothesis, the objective of this study consisted in investigating relationships between the severity of depressive symptoms and motor characteristics of Parkinson's disease. Patients and methods. Thirty patients (53 to 80 year-old) with medical diagnosis of idiopathic Parkinson's disease in initial clinic stages were studied. The Unified Parkinson's Disease Rating Scale, Hoehn-Yahr Scale, and Schwab & England Scale were used to assess the clinic signs and symptoms. The depressive symptoms were identified by complete anamnesis, examination of mental condition, and the Hamilton Rating Scale for Depression and the Anxiety and Depression Scale. Statistical analysis was performed by Pearson's correlation and multiple regression analysis. Results. A significant correlation of severity of depression symptoms with disease stage (p < 0.02), with motor signs (p < 0.008), and with functional performance (p < 0.007) was found. Conclusion. There was significant association between motor impairment and severity of depressive symptoms, and between depression and early disease onset or prolonged duration of Parkinson's disease. © 2007, Revista de Neurología.

Obsessive-compulsive disorder: Influence of age at onset on comorbidity patterns

Purpose: This study investigates the influence of age at onset of OCS on psychiatric comorbidities, and tries to establish a cut-off point for age at onset. Methods: Three hundred and thirty OCD patients were consecutively recruited and interviewed using the following structured interviews: Yale-Brown Obsessive Compulsive Scale; Yale Global Tic Severity Scale and the Structured Clinical Interview for DSM-IV. Data were analyzed with regression and cluster analysis. Results: Lower age at onset was associated with a higher probability of having comorbidity with tic, anxiety, somatoform, eating and impulse-control disorders. Longer illness duration was associated with lower chance of having tics. Female gender was associated with anxiety, eating and impulse-control disorders. Tic disorders were associated with anxiety disorders and attention-deficit/hyperactivity disorder. No cut-off age at onset was found to clearly divide the sample in homogeneous subgroups. However, cluster analyses revealed that differences started to emerge at the age of 10 and were more pronounced at the age of 17, suggesting that these were the best cut-off points on this sample. Conclusions: Age at onset is associated with specific comorbidity patterns in OCD patients. More prominent differences are obtained when analyzing age at onset as an absolute value. © 2008 Elsevier Masson SAS. All rights reserved.

Constraining the absolute neutrino mass scale and Majorana CP violating phases by future 0νββ decay experiments

Assuming that neutrinos are Majorana particles, in a three-generation framework, current and future neutrino oscillation experiments can determine six out of the nine parameters which fully describe the structure of the neutrino mass matrix. We try to clarify the interplay among the remaining parameters, the absolute neutrino mass scale and two CP violating Majorana phases, and how they can be accessed by future neutrinoless double beta (0vυββ) decay experiments, for the normal as well as for the inverted order of the neutrino mass spectrum. Assuming the oscillation parameters to be in the range presently allowed by atmospheric, solar, reactor, and accelerator neutrino experiments, we quantitatively estimate the bounds on m 0, the lightest neutrino mass, that can be inferred if the next generation 0υββ decay experiments can probe the effective Majorana mass (m ee) down to ∼1 meV. In this context we conclude that in the case that neutrinos are Majorana particles, (a) if m 0≳300 meV, i.e., within the range directly attainable by future laboratory experiments as well as astrophysical observations, then m ee≳30 meV must be observed, (b) if m 0 ≤ 300 meV, results from future 0υββ decay experiments combined with stringent bounds on the neutrino oscillation parameters, especially the solar ones, will place much stronger limits on the allowed values of m 0 than these direct experiments. For instance, if a positive signal is observed around m ee = 10 meV, we estimate 3≲m 0/meV≲65 at 95% C.L.; on the other hand, if no signal is observed down to m ee = 10 meV, then m 0≲55 meV at 95% C.L.

Caregiver report versus clinician impression: disagreements in rating neuropsychiatric symptoms in Alzheimer's disease patients

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Effects of repetitive transcranial magnetic stimulation on clinical, social, and cognitive performance in postpartum depression

Background: This randomized, placebo-controlled, double-blind pilot study evaluated the impact of repetitive transcranial magnetic stimulation (rTMS) on clinical, cognitive, and social performance in women suffering with postpartum depression. Methods: Fourteen patients were randomized to receive 20 sessions of sham rTMS or active 5 Hz rTMS over the left dorsolateral prefrontal cortex. Psychiatric clinical scales and a neuropsychological battery were applied at baseline (pretreatment), week 4 (end of treatment), and week 6 (follow-up, posttreatment week 2). Results: The active rTMS group showed significant improvement 2 weeks after the end of rTMS treatment (week 6) in Hamilton Depression Rating Scale (P = 0.020), Global Assessment Scale (P = 0.037), Clinical Global Impression (P = 0.047), and Social Adjustment Scale-Self Report-Work at Home (P = 0.020). Conclusion: This study suggests that rTMS has the potential to improve the clinical condition in postpartum depression, while producing marginal gains in social and cognitive function.

Discourse and bipolar disorder: Narrative therapy on northeast Brazil

Background: The expression 'bipolar disorder' refers to any of several psychological disorders of mood that alternate episodes of depression and mania. Also called manic depression or manic-depressive illness, it is a relatively common but unknown pathology that brings some stigmas for patients and provokes deleterious effects for their lives. This research aimed to comprehend actions, behaviors and emotions involved with bipolar disorder, through narratives of patient's personal and familiar histories. Methods: We surveyed 30 patients from a psychiatric service located in Aparecida, Paraiba, Brazil. Selected patients had bipolar disorder according to DSM-IV. For data collection, we used non-structured interview, approaching specific aspects related to bipolar disorder. Quantitative and qualitative analysis were done and Hamilton Rating Scale for Depression (HAMD) was used. Results: Most of patients presented depressive actions associated with moderate euphoria. 11 of them related familiar history of psychopathology. Mania and hippomania were prevalent on male gender, while psychotic symptoms overlay ate female. Conclusion: Patients lack a translation of behavioral and temperamental processes to minimize harm caused to their lives.

Seeing with the eyes shut: Neural basis of enhanced imagery following ayahuasca ingestion

The hallucinogenic brew Ayahuasca, a rich source of serotonergic agonists and reuptake inhibitors, has been used for ages by Amazonian populations during religious ceremonies. Among all perceptual changes induced by Ayahuasca, the most remarkable are vivid seeings. During such seeings, users report potent imagery. Using functional magnetic resonance imaging during a closed-eyes imagery task, we found that Ayahuasca produces a robust increase in the activation of several occipital, temporal, and frontal areas. In the primary visual area, the effect was comparable in magnitude to the activation levels of natural image with the eyes open. Importantly, this effect was specifically correlated with the occurrence of individual perceptual changes measured by psychiatric scales. The activity of cortical areas BA30 and BA37, known to be involved with episodic memory and the processing of contextual associations, was also potentiated by Ayahuasca intake during imagery. Finally, we detected a positive modulation by Ayahuasca of BA 10, a frontal area involved with intentional prospective imagination, working memory and the processing of information from internal sources. Therefore, our results indicate that Ayahuasca seeings stem from the activation of an extensive network generally involved with vision, memory, and intention. By boosting the intensity of recalled images to the same level of natural image, Ayahuasca lends a status of reality to inner experiences. It is therefore understandable why Ayahuasca was culturally selected over many centuries by rain forest shamans to facilitate mystical revelations of visual nature. Hum Brain Mapp, 2012. (c) 2011 Wiley Periodicals, Inc.

Circulating Glial-derived neurotrophic factor is reduced in late-life depression

Background: The Glial Cell-line derived neurotrophic factor (GDNF) is part of the TGF-beta superfamily and is abundantly expressed in the central nervous system. Changes in GDNF homeostasis have been reported in affective disorders. Aim: To assess serum GDNF concentration in elderly subjects with late-life depression, before antidepressant treatment, as compared to healthy elderly controls. Methods: Thirty-four elderly subjects with major depression and 37 age and gender-matched healthy elderly controls were included in this study. Diagnosis of major depression was ascertained by the SCID interview for DSM-IV and the severity of depressive symptoms was assessed by the Hamilton Depression Rating Scale (HDRS-21). Serum GDNF concentration were determined by sandwich ELISA. Results: Patients with major depression showed a significant reduction in GDNF levels as compared to healthy elderly controls (p < 0.001). Also, GDNF level was negatively correlated with HDRS-21 scores (r = -0.343, p = 0.003). Discussion: Our data provide evidence that GDNF may be a state marker of depressive episode in older adults. Changes in the homeostatic control of GDNF production may be a target to development of new antidepressant strategies. (C) 2011 Elsevier Ltd. All rights reserved.