Sex differences in smoking cessation: a retrospective cohort study in a psychosocial care unit in Brazil

Abstract Introduction Despite the results of epidemiological and psychometric studies reporting comparable levels of tobacco dependence among males and females, some clinical studies have detected disparities. Some smoking cessation studies based on clinical setting programs reported poorer outcomes among women than men. Methods This retrospective cohort study aimed to compare treatment success and retention between men and women on a smoking cessation program (n = 1,014) delivered at a CAPS-AD unit in Brazil. The psychological intervention lasted 6 weeks for each group of 15 patients. Each patient had to participate in weekly group cognitive-behavioral therapy (CBT) sessions and individual medical appointments during this period. These appointments were focused on the possibility of prescribing pharmacological treatment (i.e., nicotine replacement therapy, bupropion, or nortriptyline) as adjuvants to group therapy. Results The women had lower smoking severity at baseline, more clinical symptoms, and lower prevalence of alcohol and drug use disorders and were older than the men. Females had significantly higher levels of success (36.6% vs. 29.7%) and retention (51.6% vs. 41.4%) than males. Sensitivity analysis showed that female gender was significantly associated with both retention and success, among those without drug use disorders only. Conclusion Depending on the smoking cessation setting (i.e., low and middle-income countries and mental health and addiction care units), females can achieve similar and even higher quit rates than males. Previous drug use disorder was an important confounding variable in the gender outcomes analyses. Future studies should try to replicate these positive smoking cessation effects of CBT-based group therapy plus pharmacotherapy in women.

Brazilian guidelines for the management of psychomotor agitation. Part 2. Pharmacological approach

Objective: To present the essential guidelines for pharmacological management of patients with psychomotor agitation in Brazil. Methods: This is a systematic review of articles retrieved from the MEDLINE (PubMed), Cochrane Database of Systematic Reviews, and SciELO databases published from 1997 to 2017. Other relevant articles in the literature were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: Of 5,362 articles retrieved, 1,731 abstracts were selected for further reading. The final sample included 74 articles that met all inclusion criteria. The evidence shows that pharmacologic treatment is indicated only after non-pharmacologic approaches have failed. The cause of the agitation, side effects of the medications, and contraindications must guide the medication choice. The oral route should be preferred for drug administration; IV administration must be avoided. All subjects must be monitored before and after medication administration. Conclusion: If non-pharmacological strategies fail, medications are needed to control agitation and violent behavior. Once medicated, the patient should be monitored until a tranquil state is possible without excessive sedation. Systematic review registry number: CRD42017054440.

Cross-sectional study of readmissions to the psychiatric ward of Hospital Estadual Mário Covas in Santo André, state of São Paulo, between 2008 and 2015 / Estudo transversal das reinternações na enfermaria psiquiátrica do Hospital Estadual Mário Covas em Santo André, Estado de São Paulo, entre 2008 e 2015

Abstract Objectives To assess the sociodemographic and diagnostic profile of data related to psychiatric readmissions to the psychiatric ward at Hospital Estadual Mário Covas between January 2008 and September 2015, in order to investigate the possible correlation between the rate of admission and readmission and the presence or absence of a discharged patient unit or other outpatient treatment unit. Methods This was a cross-sectional, descriptive study. Data on patients readmitted during the study period were sourced from a statistical analysis of the Hospital Estadual Mário Covas database using STATA 11.0. Results During the study period, hospitalization rates decreased, while the readmission rates increased over the years, at a total of 662 readmissions. This rise in readmissions had no correlation with the presence of a discharged patient unit or other outpatient unit. Women comprised the majority of the sample, with a mean age of 42; the most prevalent disorder among women was bipolar affective disorder, while among men it was schizophrenia. The length of hospitalization increased over time, with a maximum mean time of 23 days in 2015. Most of the patients were referred from Santo André as well as from hospitals in São Paulo. Conclusion The increase in the rate of readmissions over the years suggests that the mental healthcare model may have shortcomings along the chain. It is important to understand the epidemiological profile and chain of events that led to repeated hospitalizations in order to design new strategies and approaches to care so as to keep the patients stabilized.

Resumo Objetivos Obter o perfil sociodemográfico e diagnóstico dos pacientes reinternados no Hospital Estadual Mário Covas entre janeiro de 2008 e setembro de 2015, com o intuito de investigar a possível relação entre as taxas de admissão e readmissão e a existência ou ausência do serviço para pacientes de alta clinica do hospital ou de outros serviços. Métodos Este foi um estudo descritivo transversal. Os dados foram obtidos do Hospital Estadual Mário Covas e analisados pelo programa STATA 11.0 Resultados Durante o período do estudo, as taxas de hospitalização diminuíram, enquanto as taxas de readmissão aumentaram progressivamente, com um total de 662 reinternações. O aumento dessas reinternações não teve relação com a presença da unidade pós-alta hospitalar do próprio hospital ou de outros serviços. A maioria dos pacientes era composta de mulheres, com idade média de 42 anos; o principal diagnóstico entre mulheres foi o transtorno afetivo bipolar, enquanto que para homens foi a esquizofrenia. O tempo de hospitalização aumentou com os anos, com uma média máxima em 2015 de 23 dias. A maior parte dos pacientes era referenciado de Santo André e outros hospitais de São Paulo. Conclusão O aumento das taxas de reinternação ao longo dos anos sugere que o sistema de cuidado mental tem deficiências em sua prática. É importante entender o perfil epidemiológico e a cascata de eventos que levam a rehospitalizações e, assim, traçar novas estratégias e abordagens de cuidado, mantendo os pacientes estabilizados.

Brazilian guidelines for the management of psychomotor agitation. Part 1. Non-pharmacological approach

Objective: To present the essential guidelines for non-pharmacological management of patients with psychomotor agitation in Brazil. Methods: These guidelines were developed based on a systematic review of articles published from 1997 to 2017, retrieved from MEDLINE (PubMed), Cochrane Database of Systematic Review, and SciELO. Other relevant articles identified by searching the reference lists of included studies were also used to develop these guidelines. The search strategy used structured questions formulated using the PICO model, as recommended by the Guidelines Project of the Brazilian Medical Association. Recommendations were summarized according to their level of evidence, which was determined using the Oxford Centre for Evidence-based Medicine system and critical appraisal tools. Results: We initially selected 1,731 abstracts among 5,362 articles. The final sample included 104 articles that fulfilled all the inclusion criteria. The management of agitated patients should always start with the least coercive approach. The initial non-pharmacological measures include a verbal strategy and referral of the patient to the appropriate setting, preferably a facility designed for the care of psychiatric patients with controlled noise, lighting, and safety aspects. Verbal de-escalation techniques have been shown to decrease agitation and reduce the potential for associated violence in the emergency setting. The possibility of underlying medical etiologies must be considered first and foremost. Particular attention should be paid to the patient's appearance and behavior, physical signs, and mental state. If agitation is severe, rapid tranquilization with medications is recommended. Finally, if verbal measures fail to contain the patient, physical restraint should be performed as the ultimate measure for patient protection, and always be accompanied by rapid tranquilization. Healthcare teams must be thoroughly trained to use these techniques and overcome difficulties if the verbal approach fails. It is important that healthcare professionals be trained in non-pharmacological management of patients with psychomotor agitation as part of the requirements for a degree and graduate degree. Conclusion: The non-pharmacological management of agitated patients should follow the hierarchy of less invasive to more invasive and coercive measures, starting with referral of the patient to an appropriate environment, management by a trained team, use of verbal techniques, performance of physical and mental assessment, use of medications, and, if unavoidable, use of the mechanical restraint. Systematic review registry number: CRD42017054440.

Role of personality traits in cocaine craving throughout an outpatient psychosocial treatment program

Objective: Cocaine dependence is a major international public health concern. Its chronically relapsing nature is possibly related to craving intensity, which can be influenced by diverse biological and psychological aspects. This study aimed to evaluate the role of different personality traits in craving measured throughout a psychosocial treatment program. Method: The sample comprised 66 cocaine-dependent outpatients who were enrolled in an individual and manualized cognitive-behavioral therapy program. The influence of personality traits on craving intensity, frequency, and duration was analyzed using a generalized estimating equations model with an autoregressive correlation structure. Results: Craving varied during treatment. The personality traits of novelty seeking, reward dependence, and harm avoidance interacted with craving intensity, and the personality trait of persistence interacted with craving duration throughout the treatment period. Furthermore, there were significant interactions between drug use and craving intensity, and between different routes of administration and craving intensity. Participants who used cocaine/crack while in treatment and concurrent users of crack (i.e., freebase) cocaine and powder cocaine also had a higher craving intensity. Conclusion: The extent of craving variation can depend on certain personality styles. This study shows that craving is influenced by personality traits, and this may presumably change clinical expression involved in disease. .