Tratamiento de la esquizofrenia en México: recomendaciones de un panel de expertos / Treatment of schizophrenia in Mexico: recommendations from an expert panel

Resumen La esquizofrenia es una enfermedad compleja que actualmente no tiene cura. Existen, sin embargo, numerosas terapias que, solas o en combinación, son eficaces para tratar los síntomas de la enfermedad y mantenerla bajo control. La elección del tratamiento debe ser siempre individualizada, y basarse en la presentación clínica de la enfermedad, el estado general del paciente y la eficacia del fármaco, si bien hay que considerar también el costo y el acceso a servicios y al fármaco, que en México tiene algunas limitaciones. Un panel de 12 expertos mexicanos se reunió de forma virtual para revisar los últimos datos publicados y establecer unas recomendaciones de tratamiento en México, basadas en la evidencia, que garanticen una atención médica integral, homogénea, eficiente y con calidad.

Abstract Schizophrenia is a complex illness that currently has no cure. There are, however, numerous therapies that, alone or in combination, are effective in treating the symptoms of the disease and keeping it under control. The choice of treatment must always be individualized, and based on the clinical presentation of the disease, the general condition of the patient and the efficacy of the drug, although the cost and access to services and to the drug must also be considered, as in Mexico it has some limitations. A panel of 12 Mexican experts met virtually to review the latest published data and establish evidence-based treatment recommendations in Mexico that guarantee comprehensive, homogeneous, efficient, and quality medical care.

Comorbilidad entre esquizofrenia y trastorno obsesivo compulsivo: ¿Dos entidades diferentes o un mismo espectro entre los dos trastornos?

Through the study of human psychopathology found in complex cases, where in many cases, psychiatric symptoms of various mental disorders closely coexist in the same patient. In the case of schizophrenia and obsessive compulsive disorder has been found a clear association between OCD symptoms and psychotic symptoms which in many cases difficult distinction between obsessions and delusions. For this situation currently observed in recognition than-expected rates of comorbidity and observation of development or exacerbation of obsessive compulsive symptoms during periods of exacerbation of schizophrenia. Patients with schizophrenia and OCD comorbidity may represent a special category among patients with schizophrenia, it is proposed to call it schizophrenia, schizoaffective disorder or obsessive, which established more than a clinical challenge, a challenge semiological, trying to identify and accept a new concept of obsessive idea that could involve lack of awareness of disease where the idea is not considered obsessive and excessive. We describe the case of an adult 28 years old who presents initially negative symptoms alternating with positive symptoms characteristic of schizophrenia, obsessive ideas subsequently presenting with compulsive behaviors characteristic of OCD.

Por medio del estudio de la psicopatología humana se han encontrado casos complejos en los que, en muchas ocasiones, los síntomas psiquiátricos de los diferentes trastornos mentales coexisten de manera estrecha en un mismo paciente. En el caso de la esquizofrenia y el trastorno obsesivo-compulsivo se ha encontrado una clara asociación entre los síntomas obsesivo-compulsivos y síntomas psicóticos, lo que en muchas ocasiones dificulta la delimitación entre ideas obsesivas e ideas delirantes. Por dicha situación actualmente se observa el reconocimiento de tasas mayores a las esperadas de comorbilidad y la aparición o exacerbación de los síntomas obsesivo-compulsivos durante periodos de exacerbación de la esquizofrenia. Los pacientes con comorbilidad entre esquizofrenia y TOC pueden representar una categoría especial entre los pacientes con esquizofrenia, por ello se ha propuesto denominarla trastorno esquizo-obsesivo, lo que establecería, más que un reto clínico, un reto semiológico, tratando de determinar y aceptar un nuevo concepto de idea obsesiva que pueda implicar poca conciencia de enfermedad donde no se considere la idea obsesiva como excesiva. Se describe el caso de un adulto de 28 años de edad quien presentó inicialmente síntomas negativos alternados con síntomas positivos, característicos de la esquizofrenia, a lo que se agregaron posteriormente ideas obsesivas con comportamientos compulsivos característicos del trastorno obsesivo-compulsivo.

Trastorno depresivo mayor en México: la relación entre la intensidad de la depresión, los síntomas físicos dolorosos y la calidad de vida

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SUMMARY Background: Major Depressive Disorder (MDD) is a disease associated to emotional, vegetative and physical symptoms, including for the latter those pain-related symptoms. MDD has a high prevalence rate with a substantial burden of illness, and it expected that by 2020 it will become the second cause of world disability. The diagnosis of MDD is difficult due to the high prevalence of painful physical symptoms, and also due to the fact these symptoms are more evident that the embedded emotional ones. Over 76% of patients with MDD, report painful physical symptoms observed, like headache, abdominal pain, back pain and unspecific-located pain; observing these symptoms can even predict depression severity. In addition, the likelihood of psychiatric disease increases, importantly, with the number of physical symptoms observed; moreover, the remission of physical symptoms predicts the complete remission in MDD. We present an observational, prospective study to examine the clinical profile of Mexican outpatients suffering MDD and determine the relationship between depression severity, painful physical symptoms in quality of life and depression. Methods: Adult patients with current episodes of MDD, treated with antidepressants were included. MDD was defined according to the criteria of the Statistical Manual of Mental Disorders - 4th Edition (DSM-IV) or in the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Patients should have been free of depression symptoms prior to the current episode for at least 2 months. Duration of current episode should not exceed two years. Treatment-resistant patients and those with other psychiatric diagnosis were excluded. Treatment-resistance was defined as: a) a failure to respond to treatment when two different antidepressants were employed at therapeutic doses for at least four weeks each, b) when the subject was previously treated with IMAO inhibitors, c) when electro-convulsive therapy (ECT) was previously employed. Other exclusion criteria comprise previous or current diagnosis of schizophrenia, schizophreniform or schizoaffective disorder, bipolar disorder, dementia or mental impairment. Patients were selected in 34 centers in Mexico. Patients were classified according to the presence (SFD+) or absence (SFD-) of painful physical symptoms using the Somatic Symptom Inventory (SSI); SFD+ was defined as scores ≥ 2 for the pain-related items in the SSI (items 2, 3, 9, 14, 19, 27 and 28). Visual Analogue Scale (VAS) quantified pain severity (cervical pain, headache, back pain, shoulder pain, interference of pain in daily activities and vigil-time with pain). HAMD17 and CGI-S determined depression severity, while the Quality of Life in Depression Scale (QLDS) quantified subjective well-being. Linear regression models were employed to compare groups for VAS, HAMD17, CGI-S, and QLDS, to fit the confusions or clinical predictors when needed. Proportions between groups were established with Fisher exact test or logistic regression. Significance levels were established at 0.005 due to the observational nature of the study. In the result tables, standard deviation (SD) is reported as a variation around the mean value as Mean ± SD, and 95% confidence intervals are denoted 95% IC. Results: A total of 313 patients were enrolled in the study. All of the enrolled patients were Mexican, almost them were women and had at least a previous MDD episode. Painful physical symptoms were reported by 73.7% of patients, these patients were classified into the SFD+ group. Neither statistical nor clinical significant differences between the SFD+ and SFD- groups were found when analyzing socio-demographic variables (age, gender, ethnical origin) and disease history variables (number of previous episodes of MDD, in the last 24 months, duration of current episode). At baseline, patients had a CGI-S mean score of 4.6 and HAMD17 of 26.3. HAMD17 mean score (27.1) in SFD+ patients was significantly higher (p<0.0001) than the SFD- patients (23.8), but nonsignificant differences between groups were found for the subscales central, Maier & retard. CGI-S scores were similar between SFD+ and SFD-; 4.6 and 4.5 respectively (p>0.05). Prevalent painful physical symptoms were also the most painful, when a five-point scale was employed to measure severity, and comprised muscular pain (84.9%), cervical pain (84.2%) and headache (83.5%). SFD+ patients had higher pain severity in all VAS scales (p<0.0001), with perceived severity scores twice as large when compared to SFDgroup. In particular, the global pain VAS reported average values of 49.0 and 19.7 for the SFD+ and SFD- groups respectively. Patients came to the first psychiatric consultation treated with psychotherapy (27.9%), antidepressants (37.3%), anxiolytics (28.6%) and analgesics (9.7%); more than 50% of all patients were not taking any drugs or receiving psychotherapy for treatment of MDD at baseline. Analgesics were used only by 9.7% of patients for the treatment of painful physical symptoms in their current MDD episode. No significant differences between groups were found when comparing the use of psychotherapy, antidepressants, anxiolytics, antipsychotics, mood stabilizers or analgesics. Quality of life was poor for all patients, but significantly worse in the SFD+ group than in the SFD- group (QLDS scores of 23.2 and 20.0 respectively, p<0.001). Discussion: The diagnosis and symptoms manifestation can be influenced by local socio-cultural factors, in particular cultural differences are associated with the prevalence of painful physical symptoms, but this finding is not consistent. The results of this study can be extrapolated to the MDD Mexican population, as selection criteria comprised only operative diagnosis criteria, and not enrollment into the study took place due to the presence of painful physical symptoms. Patients included into the study presented a moderate to severe disease as measured with the HAMD17 scores. The high prevalence of painful physical symptoms in patients with depression was confirmed in this study; it has been reported the patients report pain-related symptoms as the main (even the only) symptom when consulting general practitioners. Painful physical symptoms in MDD include headache, cervical pain, back pain or neck pain; the presence of painful physical symptoms in depression is associated to higher intakes medication, but in this study more than 50% of subjects were not receiving any treatment, including psychotherapy. The treatment of MDD is by no means optimal, as only 30%- 40% of these patients reach complete remission of symptoms with their first antidepressant. Psychological symptoms respond to antidepressant treatment, but in general, this is not the case for the physical symptoms. The lack of efficacy can be explained as a failure in the treatment of these painful physical symptoms. Resolving these symptoms is even a predictor for the complete remission of MDD; the evidence might suggest that treatment of emotional and physical manifestations of depression could improve successful-treatment rates. Conclusion: As found in other reports, a high prevalence of painful physical symptoms was found in MDD patients. Increase in pain severity is associated with higher HAMD17 scores but not CGI-S scores; this discrepancy in the final rates obtained with both scales suggests that both emotional and physical dimensions of MDD should be considered when the clinical assessment is performed. We concluded that clinical judgment of Mexican psychiatrists differs between their global impression and a semi-structured interview in the same patient and therefore is fundamental that the clinical evaluation consists of both emotional and physical manifestations as important components of MDD.

Motivos de interconsulta psiquiátrica en pacientes con delirium / Psychiatric consultation motives in patients with delirium

Antecedentes: el delirium e un trastorno mental muy común y potencialmente fatal; por ello es necesario saber cómo detectarlo y, por ende, establecer procesos de diagnóstico más eficases y oportunos. Objetivo: evaluar las manifestaciones clínicas que generen la solicitud de interconsultas psiquiátricas a pacientes con diagnóstico definitivo de delirium. Material y métodos: se revisaron 1,474 referencias al Departamento de Psiquiatría del Hospital de Especialidades, del Centro Médico Nacional Siglo XXI, hechas entre 1995 y 1997. Todos los diagnósticos se realizaron de acuerdo con los criterios del DSM.IV. Resultados: doscientos dieciocho pacientes tuvieron delirium (14.7 por ciento); y las principales alteraciones de éstos fueron cognitivas (36.6 por ciento), de la conducta (21 por ciento y del afecto (20 por ciento). Conclusiones. es muy común que se confunda el delirium con la depresión. Entre los mismos servicios médicos y quirúrgicos hay diferencias en la apreciación de estas alteraciones, ya que los primeros descubren más trastornos del afecto, mientras que los segundos encuentran más cambios de la conciencia. Por otra parte, en cuanto al género de los pacientes, se identificaron más alteraciones efectivas en la mujer y cognitivas en el hombre

Inhibidores selectivos de la recaptura de serotonina / Selective serotonin reuptake inhibitors

Tres de los inhibidores selectivos de la recaptura de serotonina estarán disponibles para el uso de los pacientes psiquiátricos atendidos en el Instituto Mexicano del Sguro Social, por lo que consideramos interesante revisar algunos de los aspectos que los diferencian entre sí y de los antidepresivos tricíclicos tradicionales. Los inhibidores selectivos de la recaptura de serotonina son psicofármacos antidepresivos que han mostrado la capacidad de inhibir potente y selectivamente la recaptura de serotonina (5-hidroxitriptamina), una indolamina que participa en una serie de situaciones clínicas de gran importancia particularmente en psiquiatría, como trastornos efectivos, ansiosos, obsesivo compulsivos, alcoholismo, control de impulsos y conducta alimentaria, por mencionar algunos. Se describen las caracteristícas farmacocinéticas, farmacodinámicas, efectos colaterales y perfiles terapéuticos de los inhibidores selectivos de la recaptura de serotonina, comparándolos con los antidepresivos tricíclicos tradicionales. Se analizan los motivos por los que se consideran fármacos de mayor seguridad y torabilidad, especialmente en el paciente médicamente enfermo con comorbilidad psiquiátrica asociada