Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part II: cognitive-behavioral therapy

Objectives: To summarize evidence-based cognitive-behavioral therapy (CBT) treatment and propose clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The literature on CBT interventions for adult OCD, including BT and exposure and response prevention, was systematically reviewed to develop updated clinical guidelines for clinicians, providing comprehensive details about the necessary procedures for the CBT protocol. We searched the literature from 2013-2020 in five databases (PubMed, Cochrane, Embase, PsycINFO, and Lilacs) regarding study design, primary outcome measures, publication type, and language. Selected articles were assessed for quality with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association. Results: We examined 44 new studies used to update the 2013 American Psychiatric Association guidelines. High-quality evidence supports CBT with exposure and response prevention techniques as a first-line treatment for OCD. Protocols for Internet-delivered CBT have also proven efficacious for adults with OCD. Conclusion: High-quality scientific evidence supports the use of CBT with exposure and response prevention to treat adults with OCD.

Translating measurement into practice: Brazilian norms for depressive symptom assessment with the Patient Health Questionnaire (PHQ-9)

Objectives: To provide practical norms for measuring depressive symptoms with the Patient Health Questionnaire 9 (PHQ-9) in Brazil through a state-of-the-art psychometrics analysis. Methods: We used a large representative dataset from the 2019 Brazilian National Health Survey (Pesquisa Nacional de Saúde - 2019), which included 90,846 Brazilian citizens. To assess scale structure, we assessed a unidimensional model using confirmatory factor analysis. Item response theory was used to characterize the distribution of depressive symptoms. Summed- and mean-based PHQ-9 scores were then linked using item response theory-based scores in generalized additive models. Finally, percentiles, T scores, and a newly developed score, called the decimal score (D score), were generated to describe PHQ-9 norms for the Brazilian population. Results: Confirmatory factor analysis revealed a good fit to the unidimensional model, being invariant to age and sex. Item response theory captured item-level information about the latent trait (reliable from 1 to 3 SDs above the mean). Brazilian norms were presented using summed scores, T scores, and D scores. Conclusion: This is the first study to determine Brazilian norms for the PHQ-9 among a large representative sample using robust psychometric tools. More precise PHQ-9 scores are now available and may be widely used in primary and specialized clinical care settings.

Brazilian Research Consortium on Obsessive-Compulsive Spectrum Disorders guidelines for the treatment of adult obsessive-compulsive disorder. Part I: pharmacological treatment

Objectives: To summarize evidence-based pharmacological treatments and provide guidance on clinical interventions for adult patients with obsessive-compulsive disorder (OCD). Methods: The American Psychiatric Association (APA) guidelines for the treatment of OCD (2013) were updated with a systematic review assessing the efficacy of pharmacological treatments for adult OCD, comprising monotherapy with selective serotonin reuptake inhibitors (SSRIs), clomipramine, serotonin and norepinephrine reuptake inhibitors (SNRIs), and augmentation strategies with clomipramine, antipsychotics, and glutamate-modulating agents. We searched for the literature published from 2013-2020 in five databases, considering the design of the study, primary outcome measures, types of publication, and language. Selected articles had their quality assessed with validated tools. Treatment recommendations were classified according to levels of evidence developed by the American College of Cardiology and the American Heart Association (ACC/AHA). Results: We examined 57 new studies to update the 2013 APA guidelines. High-quality evidence supports SSRIs for first-line pharmacological treatment of OCD. Moreover, augmentation of SSRIs with antipsychotics (risperidone, aripiprazole) is the most evidence-based pharmacological intervention for SSRI-resistant OCD. Conclusion: SSRIs, in the highest recommended or tolerable doses for 8-12 weeks, remain the first-line treatment for adult OCD. Optimal augmentation strategies for SSRI-resistant OCD include low doses of risperidone or aripiprazole. Pharmacological treatments considered ineffective or potentially harmful, such as monotherapy with antipsychotics or augmentation with ketamine, lamotrigine, or N-acetylcysteine, have also been detailed.

Identifying Depression Early in Adolescence: assessing the performance of a risk score for future onset of depression in an independent Brazilian sample

Objective: The Identifying Depression Early in Adolescence Risk Score (IDEA-RS) was recently developed in Brazil using data from the Pelotas 1993 Birth Cohort to estimate the individualized probability of developing depression in adolescence. This model includes 11 sociodemographic variables and has been assessed in longitudinal studies from four other countries. We aimed to test the performance of IDEA-RS in an independent, community-based, school-attending sample within the same country: the Brazilian High-Risk Cohort. Methods: Standard external validation, refitted, and case mix-corrected models were used to predict depression among 1442 youth followed from a mean age of 13.5 years at baseline to 17.7 years at follow-up, using probabilities calculated with IDEA-RS coefficients. Results: The area under the curve was 0.65 for standard external validation, 0.70 for the case mix-corrected model, and 0.69 for the refitted model, with discrimination consistently above chance for predicting depression in the new dataset. There was some degree of miscalibration, corrected by model refitting (calibration-in-the-large reduced from 0.77 to 0). Conclusion: IDEA-RS was able to parse individuals with higher or lower probability of developing depression beyond chance in an independent Brazilian sample. Further steps should include model improvements and additional studies in populations with high levels of subclinical symptoms to improve clinical decision making.

Inattention symptoms in early pregnancy predict parenting skills and infant maltreatment during the first year of life

Objective: Maternal attention-deficit/hyperactivity disorder has not been investigated in relation to parenting skills in adolescent mothers. This study investigated whether maternal inattention and hyperactivity/impulsivity symptoms early in pregnancy predict poorer parenting skills and infant maltreatment during the first year of life in adolescent mothers living in adverse environmental conditions. Methods: The participants in this study were 80 adolescent mothers aged 14-19 years and their babies who were taking part in a randomized controlled trial on the effects of a home-visiting program on infant development. Symptoms of maternal attention-deficit/hyperactivity disorder were assessed in the first trimester of pregnancy. Parenting skills (maternal competence, attachment to the baby, home environment) and child maltreatment were assessed when the infants were aged 6 and 12 months. Multilevel linear regression models were constructed to test the extent to which prenatal maternal inattention and hyperactivity/impulsivity symptoms predicted these parenting variables during the first year of the infant's life. Results: Prenatal inattention symptoms significantly predicted lower maternal competence and attachment, a poorer home environment, and greater maltreatment during the first year of life. Hyperactivity did not significantly predict parenting skills or maltreatment. Conclusions: Our findings suggest that inattention symptoms may interfere with parenting abilities in adolescent mothers and should be considered in early intervention programs.

Neurocircuit models of obsessive-compulsive disorder: limitations and future directions for research

Obsessive-compulsive disorder (OCD) is a common psychiatric condition classically characterized by obsessions (recurrent, intrusive and unwanted thoughts) and compulsions (excessive, repetitive and ritualistic behaviors or mental acts). OCD is heterogeneous in its clinical presentation and not all patients respond to first-line treatments. Several neurocircuit models of OCD have been proposed with the aim of providing a better understanding of the neural and cognitive mechanisms involved in the disorder. These models use advances in neuroscience and findings from neuropsychological and neuroimaging studies to suggest links between clinical profiles that reflect the symptoms and experiences of patients and dysfunctions in specific neurocircuits. Several models propose that treatments for OCD could be improved if directed to specific neurocircuit dysfunctions, thereby restoring efficient neurocognitive function and ameliorating the symptomatology of each associated clinical profile. Yet, there are several important limitations to neurocircuit models of OCD. The purpose of the current review is to highlight some of these limitations, including issues related to the complexity of brain and cognitive function, the clinical presentation and course of OCD, etiological factors, and treatment methods proposed by the models. We also provide suggestions for future research to advance neurocircuit models of OCD and facilitate translation to clinical application.

Factor structure of the Dimensional Yale-Brown Obsessive-Compulsive Scale in a large sample of adults with obsessive-compulsive disorder

Objectives: Although the Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) is a widely used instrument for assessing different obsessive-compulsive symptom dimensions, its factor structure has never been studied in a Brazilian population. Thus, we aimed to assess the goodness-of-fit indexes and factor loadings of two higher-order models of the DY-BOCS using confirmatory factor analysis (CFA) in a large obsessive-compulsive disorder (OCD) sample. Methods: We tested two CFA models in a sample of 955 adults with OCD who had been assessed with the DY-BOCS in a cross-sectional multi-site study. The first model encompassed the symptom checklist (present or absent), whereas the second focused on items related to severity scores. Results: Both models presented adequate goodness-of-fit indexes. The comparative fit index, Tucker-Lewis index, and omega were > 0.9, while the root mean square error of approximation was ≤ 0.06 for both models. Factor loadings for each item of each dimension are presented and discussed. Conclusion: Higher-order factor models showed adequate goodness-of-fit indexes, indicating that they appropriately measured OCD dimensions in this Brazilian population.

Disability in children and adolescents: the extent of the impact on psychiatric disorders and educational deficits

Abstract Introduction Most children/adolescents with disability live in low and middle-income countries and, worldwide, they are more likely to have mental health problems and achieve worse academic performance compared to those with typical development. Objective To assess whether Brazilian children/adolescents with four types of disabilities are more likely to have psychiatric disorders and educational deficits than children/adolescents with typical development. Method A multicenter cross-sectional study involving a school-based probabilistic sample of second to sixth graders (N = 1,674) from public schools in four Brazilian regions. The four types of disabilities (intellectual, visual, hearing, and motor) were assessed using the Ten Questions Questionnaire. Psychiatric disorders were measured with the Schedule for Affective Disorders/Schizophrenia for School-Age Children (K-SADS-PL), and academic performance was evaluated using the Teste de Desempenho Acadêmico - TDE (the academic performance test). Results A logistic regression model with cluster-robust errors identified the following statistically significant associations with three of the four types of disability (the exception was hearing). Intellectual disability was associated with anxiety (p < 0.01), depression (p < 0.01), attention deficit hyperactivity disorder (ADHD) (p < 0.001), school failure (p < 0.01), and poor academic performance (p < 0.01). Visual disability was associated with depression (p < 0.01). Motor disability was marginally associated with ADHD (p = 0.08). Conclusions Presence of disabilities (intellectual, visual, and motor) in children/adolescents was associated with psychiatric disorders, school failure, and academic performance. It is therefore important to identify presence of disabilities and plan and deliver specific interventions and specialized educational care for the needs presented by these children/adolescents. This is particularly important in low and middle-income countries, where these disabilities are frequent among children/adolescents.

Predictors of gaming disorder in children and adolescents: a school-based study

Objective: To determine whether psychiatric and gaming pattern variables are associated with gaming disorder in a school-based sample. Methods: We analyzed data from the Brazilian High-Risk Cohort for Psychiatric Disorders, a community sample aged 10 to 18, using questionnaires on gaming use patterns. We applied the Gaming Addiction Scale to diagnose gaming disorder and the Development and Well-Being Behavior Assessment for other diagnoses. Results: Out of 407 subjects, 83 (20.4%) fulfilled the criteria for gaming disorder. More role-playing game players were diagnosed with gaming disorder that any other genre. Gaming disorder rates increased proportionally to the number of genres played. Playing online, being diagnosed with a mental disorder, and more hours of non-stop gaming were associated with higher rates of gaming disorder. When all variables (including age and gender) were considered in a logistic regression model, the number of genres played, the number of non-stop hours, the proportion of online games, and having a diagnosed mental disorder emerged as significant predictors of gaming disorder. Conclusion: Each variable seems to add further risk of gaming disorder among children and adolescents. Monitoring the length of gaming sessions, the number and type of genres played, time spent gaming online, and behavior changes may help parents or guardians identify unhealthy patterns of gaming behavior.

COMVC-19: A Program to protect healthcare workers' mental health during the COVID-19 Pandemic. What we have learned

OBJECTIVE: In 2020, the COVID-19 pandemic brought a work and stress overload to healthcare workers, increasing their vulnerability to mental health impairments. In response, the authors created the COMVC-19 program. The program offered preventive actions and mental health treatment for the 22,000 workers of The Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP). This paper aims to describe its implementation and share what we have learned from this experience. METHODS: Workers were able to easily access the program through a 24/7 hotline. Additionally, a mobile phone app that screened for signs and symptoms of emotional distress and offered psychoeducation and/or referral to treatment was made available. Data from both these sources as well as any subsequent psychiatric evaluations were collected. RESULTS: The first 20 weeks of our project revealed that most participants were female, and part of the nursing staff working directly with COVID-19 patients. The most frequently reported symptoms were: anxiety, depression and sleep disturbances. The most common diagnoses were Adjustment, Anxiety, and Mood disorders. CONCLUSIONS: Implementing a mental health program in a multimodal intervention was feasible in a major quaternary public hospital. Our data also suggests that preventive actions should primarily be aimed at anxiety and depression symptoms, with a particular focus on the nursing staff.

Population neuroscience: challenges and opportunities for psychiatric research in low- and middle-income countries

Objective: Population neuroscience is an emerging field that combines epidemiology and neuroscience to study how genes and the environment shape typical and atypical brain functioning. The objective of this study was to review key studies on population neuroscience from low- and middle-income countries (LMICs) and to identify potential gaps vis-à-vis studies conducted in high-income countries. Methods: We conducted a systematic review to search for longitudinal cohort studies investigating the development of psychiatric disorders in children and adolescents in LMICs. We performed an electronic search in the EMBASE and MEDLINE databases from inception to July 5th, 2019. Results: We found six cohorts from four countries that met our search criteria: three cohorts from Brazil, one from China, one from South Africa, and one from Mauritius. Relevant examples of findings from these studies are reported. Conclusion: Our results demonstrate the impact of the valuable science output these cohort designs promote, allowing LMICs to have a share in frontline global psychiatry research. National and international funding agencies should invest in LMIC population neuroscience in order to promote replication and generalization of research from high-income countries.

Theoretical models of Obsessive-Compulsive Disorder (OCD): a perspective on future approaches

Obsessive-Compulsive disorder (OCD) is a common psychiatric condition that leads to significant impairment in everyday life. Advancements in neurobiological investigations contributed to a better understanding of pathophysiological mechanisms behind OCD, leading to the understanding that current models employed to conceptualize OCD are not adequate and might be a significant factor in precluding further advancements in how OCD is treated. In this paper, we will use OCD as a model to discuss the limitations of the current diagnostic systems in Psychiatry and to present the novel perspectives based on neurobiological findings that might lead to considerable advancements in treatments for OCD.

No evidence of attentional bias toward angry faces in patients with obsessive-compulsive disorder

Objective: Although attentional bias (AB) toward angry faces is well established in patients with anxiety disorders, it is still poorly studied in obsessive-compulsive disorder (OCD). We investigated whether OCD patients present AB toward angry faces, whether AB is related to symptom severity and whether AB scores are associated with specific OCD symptom dimensions. Method: Forty-eight OCD patients were assessed in clinical evaluations, intelligence testing and a dot-probe AB paradigm that used neutral and angry faces as stimuli. Analyses were performed with a one-sample t-test, Pearson correlations and linear regression. Results: No evidence of AB was observed in OCD patients, nor was there any association between AB and symptom severity or dimension. Psychiatric comorbidity did not affect our results. Conclusion: In accordance with previous studies, we were unable to detect AB in OCD patients. To investigate whether OCD patients have different brain activation patterns from anxiety disorder patients, future studies using a transdiagnostic approach should evaluate AB in OCD and anxiety disorder patients as they perform AB tasks under functional neuroimaging protocols.

Obsessive-compulsive symptoms in children with first degree relatives diagnosed with obsessive-compulsive disorder

Objective: A first-degree relative affected by obsessive-compulsive disorder (OCD) and obsessive-compulsive symptoms (OCS) in childhood is an important risk factor for developing the disorder in adulthood. The relationship between a family history of OCD and the presence of OCS and its correlates in childhood is not well established. Methods: A total of 66 children whose parents or siblings have been diagnosed with OCD were assessed for the presence of OCS and clinical correlates. Results: Three children (4.5%) were reported to have received an OCD diagnosis and another 26 (39.4%) were identified as having OCS. Children with OCS had higher rates of coercive behavior and came from families with lower socioeconomic status. Contamination/cleaning dimension symptoms in the proband were associated with OCS in the assessed children. Conclusion: OCS are frequent among family members of individuals with OCD and are associated with socioeconomic status, coercive behaviors and proband contamination/cleaning symptoms. Future longitudinal studies should test the risk of developing OCD in association with these characteristics.

Diagnostic operationalization and phenomenological heterogeneity in psychiatry: the case of attention deficit hyperactivity disorder / Operacionalización diagnóstica y heterogeneidad fenomenológica en psiquiatría: el caso del trastorno por déficit de atención con hiperactividad

Abstract Introduction We assessed the impact of polythetic conceptualizations of mental disorders on the validity and reliability of psychiatric diagnosis, with a specific focus on two levels of heterogeneity: phenomenological and pathophysiological. Objective We investigated this issue using attention deficit hyperactivity disorder (ADHD) as an example. Method We examined individuals from two samples enriched for psychopathology (n = 1 255 children in Porto Alegre and 1 257 children in São Paulo, Brazil). We conducted a series of data analyses to investigate phenomenological heterogeneity, including confirmatory factor analysis. We also investigated pathophysiological heterogeneity using symptom-level regressions between ADHD symptoms and four neurocognitive processes consistently linked to ADHD (working memory, inhibitory control, intra-subject variability in reaction times, and temporal processing). Lastly, we assessed the performance of polythetic systems for reliability testing inter-rater and test-rest reliability of two well-known symptomatic scales. Results Among the 116 200 possible combinations of symptoms to achieve DSM symptomatic threshold for categorical ADHD diagnosis, we found 173 combinations in the two independent samples, and only four were replicated in both samples (2.3%). We also found that the number of ADHD symptoms is a poor indicator of variation in the general ADHD latent trait. Overall, symptoms did not have specific profiles of associations with any of the neurocognitive processes. Reliability analyses revealed that increasing the number of items augments overall reliability of measurements. Discussion and conclusion Our findings illustrate both potential benefits and problems inherent to the polythetic system for ADHD. Implications for the search of mechanisms underlying psychiatric disorders are discussed.

Resumen Antecedentes Evaluamos el impacto de las conceptualizaciones politécnicas de los trastornos mentales en la validez y la fiabilidad del diagnóstico psiquiátrico, con un enfoque específico en dos niveles de heterogeneidad: fenomenológico y fisiopatológico. Objetivos Investigamos este problema utilizando el trastorno por déficit de atención e hiperactividad (TDAH) como ejemplo. Método Examinamos individuos de dos muestras enriquecidas por psicopatología (n = 1 255 niños en Porto Alegre y 1 257 niños en São Paulo, Brasil). Llevamos a cabo una serie de análisis de datos para investigar la heterogeneidad fenomenológica, incluido el análisis factorial confirmatorio. También investigamos la heterogeneidad fisiopatológica utilizando regresiones al nivel de síntomas entre los síntomas del TDAH y cuatro procesos neurocognitivos consistentemente vinculados al TDAH (memoria de trabajo, control inhibitorio, variabilidad intrasujeto en tiempos de reacción y procesamiento temporal). Por último, evaluamos el rendimiento de los sistemas politéticos para la prueba de confiabilidad interevaluador y la confiabilidad test-rest de dos escalas sintomáticas bien conocidas. Resultados Entre las 116 200 posibles combinaciones de síntomas para alcanzar el umbral sintomático del DSM para el diagnóstico categórico de TDAH, encontramos 173 combinaciones en las dos muestras independientes y sólo cuatro se replicaron en ambas muestras (2.3%). También encontramos que la cantidad de síntomas de TDAH no es un buen indicador de la variación en el rasgo latente general del TDAH. En general, los síntomas no tenían perfiles específicos de asociaciones con ninguno de los procesos neurocognitivos. Los análisis de confiabilidad revelaron que aumentar el número de artículos aumenta la confiabilidad general de las mediciones. Discusión y conclusión Nuestros hallazgos ilustran tanto los beneficios potenciales como los problemas inherentes al sistema politécnico para el TDAH. Se discuten las implicaciones para la búsqueda de mecanismos subyacentes a los trastornos psiquiátricos.