Challenges and potential solutions for physician suicide risk factors in the COVID-19 era: psychiatric comorbidities, judicialization of medicine, and burnout

Abstract Introduction Suicide among physicians constitutes a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in general, despite an overall contraction in physician mortality rates in both genders. Methods This narrative review was conducted by searching and analyzing articles/databases that were relevant to addressing questions raised by a prior meta-analysis and how they might be affected by COVID-19. This process included unstructured searches on Pubmed for physician suicide, burnout, judicialization of medicine, healthcare organizations, and COVID-19, and Google searches for relevant databases and medical society, expert, and media commentaries on these topics. We focus on three factors critical to addressing physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. Results We found relevant articles on suicide reporting, physician mental health, the effects of healthcare judicialization, and organizational involvement on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physician suicide rates, inadequate diagnosis and management of psychiatric comorbidities and the chronic effects on physicians' work capacity, and, finally, judicialization of medicine and organizational failures increasing physician burnout. We discuss these factors in general and in relation to the COVID-19 pandemic. Conclusions We present an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors.

Effective recommendations towards healthy routines to preserve mental health during the COVID-19 pandemic

Objective: To assess the adherence to a set of evidence-based recommendations to support mental health during the coronavirus disease 2019 (COVID-19) pandemic and its association with depressive and anxiety symptoms. Methods: A team of health workers and researchers prepared the recommendations, formatted into three volumes (1: COVID-19 prevention; 2: Healthy habits; 3: Biological clock and sleep). Participants were randomized to receive only Volume 1 (control), Volumes 1 and 2, Volumes 1 and 3, or all volumes. We used a convenience sample of Portuguese-speaking participants over age 18 years. An online survey consisting of sociodemographic and behavioral questionnaires and mental health instruments (Patient Health Questionnaire-9 [PHQ-9] and Generalized Anxiety Disorder-7 [GAD-7]) was administered. At 14 and 28 days later, participants were invited to complete follow-up surveys, which also included questions regarding adherence to the recommendations. A total of 409 participants completed the study - mostly young adult women holding university degrees. Results: The set of recommendations contained in Volumes 2 and 3 was effective in protecting mental health, as suggested by significant associations of adherence with PHQ-9 and GAD-7 scores (reflecting anxiety and depression symptoms, respectively). Conclusion: The recommendations developed in this study could be useful to prevent negative mental health effects in the context of the pandemic and beyond.

Lifestyle predictors of depression and anxiety during COVID-19: a machine learning approach

Abstract Introduction Recent research has suggested an increase in the global prevalence of psychiatric symptoms during the COVID-19 pandemic. This study aimed to assess whether lifestyle behaviors can predict the presence of depression and anxiety in the Brazilian general population, using a model developed in Spain. Methods A web survey was conducted during April-May 2020, which included the Short Multidimensional Inventory Lifestyle Evaluation (SMILE) scale, assessing lifestyle behaviors during the COVID-19 pandemic. Depression and anxiety were examined using the PHQ-2 and the GAD-7, respectively. Elastic net, random forest, and gradient tree boosting were used to develop predictive models. Each technique used a subset of the Spanish sample to train the models, which were then tested internally (vs. the remainder of the Spanish sample) and externally (vs. the full Brazilian sample), evaluating their effectiveness. Results The study sample included 22,562 individuals (19,069 from Brazil, and 3,493 from Spain). The models developed performed similarly and were equally effective in predicting depression and anxiety in both tests, with internal test AUC-ROC values of 0.85 (depression) and 0.86 (anxiety), and external test AUC-ROC values of 0.85 (depression) and 0.84 (anxiety). Meaning of life was the strongest predictor of depression, while sleep quality was the strongest predictor of anxiety during the COVID-19 epidemic. Conclusions Specific lifestyle behaviors during the early COVID-19 epidemic successfully predicted the presence of depression and anxiety in a large Brazilian sample using machine learning models developed on a Spanish sample. Targeted interventions focused on promoting healthier lifestyles are encouraged.

From anatomy to function: the role of the somatosensory cortex in emotional regulation

Since the pioneering work of Penfield and his colleagues in the 1930s, the somatosensory cortex, which is located on the postcentral gyrus, has been known for its central role in processing sensory information from various parts of the body. More recently, a converging body of literature has shown that the somatosensory cortex also plays an important role in each stage of emotional processing, including identification of emotional significance in a stimulus, generation of emotional states, and regulation of emotion. Importantly, studies conducted in individuals suffering from mental disorders associated with abnormal emotional regulation, such as major depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety and panic disorders, specific phobia, obesity, and obsessive-compulsive disorder, have found structural and functional changes in the somatosensory cortex. Common observations in the somatosensory cortices of individuals with mood disorders include alterations in gray matter volume, cortical thickness, abnormal functional connectivity with other brain regions, and changes in metabolic rates. These findings support the hypothesis that the somatosensory cortex may be a treatment target for certain mental disorders. In this review, we discuss the anatomy, connectivity, and functions of the somatosensory cortex, with a focus on its role in emotional regulation.

Mitochondrial Dysfunction in Bipolar Disorder: Lessons from Brain Imaging and Molecular Markers / Disfunción mitocondrial en el trastorno bipolar: lecciones de las imágenes cerebrales y los marcadores moleculares

Bipolar disorder (BD) is a chronic major mental illness characterized by extreme mood episodes, cognitive impairment, and high rates of disability. Several lines of evidence suggest that BD may be associated with abnormalities in mitochondrial function. Here we critically review findings from brain imaging and from preclinical studies that investigated markers of energy metabolism in BD. Research with postmortem brain and peripheral tissue revealed changes in size and distribution of mitochondria, as well as decreased mitochondrial electron transport chain function, increased oxidative stress, and increased lipid and protein damage. PET imaging studies revealed decreased glucose metabolism in sub-areas of the prefrontal cortex, amygdala, and hippocampus structures in BD. On the other hand, increased lactate levels in BD have been found in cerebrospinal fluid and in gray matter by magnetic resonance spectroscopy, which suggest that distinct pathophysiological processes may be region-specific. Resting state fMRI studies have demonstrated decreased functional connectivity between fronto-limbic circuits. In conclusion, these results support the hypothesis of mitochondrial dysfunction in BD and suggest that BD is associated with decreased energy production and a shift towards anaerobic glycolysis. Such changes in energy metabolism can potentially decrease cell plasticity and ultimately disrupt brain circuits associated with mood and cognitive control.

El trastorno bipolar (TB) es una enfermedad mental crónica grave caracterizada por episodios de ánimo extremo, trastornos cognitivos y altas tasas de discapacidad. Varias líneas de evidencia sugieren que el TB puede estar asociado con anormalidades en la función mitocondrial. Aquí analizamos críticamente los hallazgos de las imágenes cerebrales y de los estudios preclínicos que han investigado los marcadores del metabolismo de energía en TB. Las investigaciones post mórtem basadas en tejidos cerebrales y tejidos periféricos revelaron cambios en el tamaño y en la distribución de las mitocondrias, además de una disminución en la funcionalidad de la cadena de transporte de electrones de las mitocondrias, un mayor estrés oxidativo y mayores daños lipídicos y proteínicos. Estudios con imágenes TEP revelan un metabolismo de glucosa disminuido en las subáreas de la corteza prefrontal, la amígdala y el hipocampo en TB. Por otro lado, se han hallado concentraciones mayores de lactato en TB en el líquido cefalorraquídeo cerebral y en la materia gris utilizando la espectroscopia con resonancia magnética, lo cual sugiere que los procesos fisiopatológicos individuales pueden ser específicos de las distintas regiones. Los estudios con resonancias magnéticas funcionales han demostrado una menor conectividad funcional entre los circuitos frontolímbicos. En conclusión, estos resultados apoyan la hipótesis de una disfunción mitocondrial en el TB y sugieren que el TB está asociado con una menor producción de energía y un cambio hacia la glicólisis anaeróbica. Estos cambios en el metabolismo energético pueden disminuir potencialmente la plasticidad celular y, en últimas, perturbar los circuitos cerebrales asociados con el estado de ánimo y el control cognitivo.

Características clínicas e história familiar em pacientes ambulatoriais com transtorno obsessivo-compulsivo / Clinical features and family history in obsessive-compulsive outpatients

INTRODUÇÃO: A ocorrência familiar do transtorno obsessivo-compulsivo permite-nos especular sobre diferenças clínicas entre indivíduos com história familiar de TOC (HF+) e sem história familiar de TOC (HF-). Este estudo investigou a associação entre história familiar de TOC e algumas características clínicas. MATERIAL E MÉTODOS: Foram estudados retrospectivamente 111 pacientes através de revisão de prontuários de atendimento no Hospital Materno-Infantil Presidente Vargas de Porto Alegre, no período de julho de 1994 até julho de 2002. RESULTADOS: A idade média de início dos sintomas foi menor no grupo HF+ (17,8 anos ± 8,69 versus 20,8 anos ± 9,65; p = 0,000963). A intensidade dos sintomas obsessivo-compulsivos medidos pela YBOCS foi mais grave no grupo HF+ (22,5 ± 4,16 versus 17,93 ± 9,95; p < 0,001). Encontrou-se uma incidência maior de colecionismo no grupo HF+: quatro de 15 pacientes (26,6 por cento) versus três de 69 pacientes (4,3 por cento); p = 0,029. Não houve diferença relevante na variedade de fármacos utilizados no tratamento dos grupos estudados, bem como na freqüência da aplicação da terapia cognitivo-comportamental. Oito de 15 pacientes (53,3 por cento) com história familiar e 13 de 69 pacientes (18,8 por cento) sem história familiar necessitaram de terapia complementar à farmacológica (p = 0,022). CONCLUSÃO: Em resumo, os pacientes portadores de TOC com história familiar positiva para o mesmo, em nosso estudo, mostraram início dos sintomas mais precoce, maior gravidade dos sintomas medidos pela YBOCS e maior complexidade terapêutica, além de presença mais freqüente de colecionismo. Estudos prospectivos, com informações colhidas diretamente dos pacientes e dos familiares, além da inclusão de grupos-controle randomizados, poderão evidenciar adequadamente esses resultados.