La depresión: un desafío en la práctica médica general / La depresión: un desafío en la práctica médica general

Asociada o no a una enfermedad orgánica, la depresión tiene gran prevalencia en la práctica médica pero es subdiagnosticada. El trastorno del ánimo suele coexistir con variadas quejas somáticas y dolores crónicos, configurando síndromes mixtos con un diagnóstico diferencial complejo. En este artículo se describen distintas presentaciones clínicas de la depresión en medicina general, con énfasis en los estados depresivos atípicos, depresiones enmascaradas muy relevantes por su frecuencia y consecuencias: depresión posquirúrgica, cuadros dolorosos crónicos como cefaleas o lumbago, la fatiga crónica y la fibromialgia. Solo el reconocimiento y diagnóstico de la depresión subyacente posibilitará la implementación de las adecuadas intervenciones terapéuticas. Se revisan también algunas recomendaciones para el uso de antidepresivos en atención primaria y la eventual consulta psiquiátrica. (AU)

Associated or not with an organic disease, depression has a high prevalence in medical practice but is underdiagnosed. The mood disorder usually coexists with varied somatic complaints and chronic pain, forming mixed syndromes with a complex differential diagnosis. This article describes different clinical presentations of depression in general medicine, with emphasis on atypical depressive states, masked depressions very relevant for their frequency and consequences: post-surgical depression, chronic painful conditions such as headaches or lumbago, chronic fatigue and fibromyalgia. Only the recognition and diagnosis of the underlying depression will enable the implementation of appropriate therapeutic interventions. Some recommendations for the use of antidepressant drugs in primary care and the eventual psychiatric consultation are also reviewed. (AU)

Associação de Diabetes Mellitus com transtornos alimentares / Association of Diabetes Mellitus with eating disorders

O objetivo deste estudo foi revisar na literatura a associa��o do Diabetes Mellitus com os transtornos alimentares, bem como a influ�ncia desses transtornos sobre o controle metab�lico de pacientes com Diabetes Mellitus. Realizaram-se consultas aos bancos de dados Biblioteca Regional de Medicina ? Centro Latino-Americano e do Caribe de Informa��o em Ci�ncias da Sa�de; National Library of Medicine, Estados Unidos, e Scientific Electronic Library Online, publicados on-line entre 1992 e 2013, bem como trabalhos acad�micos e livros-texto. A maioria dos estudos revelou que a omiss�o/redu��o de insulina e o transtorno alimentar no Diabetes Mellitus Tipo 1 estiveram relacionados ao deficiente controle metab�lico, enquanto que a compuls�o alimentar no Diabetes Mellitus tipo 2 (com sobrepeso ou obesidade) parece ter rela��o com preju�zo na sa�de f�sica. H� v�rios relatos de que o Diabetes Mellitus tipo 2 associado ao transtorno da compuls�o alimentar peri�dica n�o influencia os resultados da Hemoglobina A Glicosilada. Al�m disso, h� evid�ncias de maior incid�ncia de depress�o entre os pacientes diab�ticos, fato que parece estar vinculado a altera��es no curso cl�nico da doen�a. Deve-se investigar a presen�a de comorbidades, como o transtorno alimentar no paciente com Diabetes Mellitus, visto que, juntos, os dist�rbios representam um problema no tratamento deste grupo de pacientes, tornando necess�rio um olhar atento na preserva��o do controle metab�lico adequado e na manuten��o da qualidade de vida dos pacientes.

The aim of this study was to review in the literature the association between diabetes and eating disorders, as well as the influence of this disorders on the metabolic control of patients with diabetes mellitus. There were queries to Regional Library of Medicine - The Latin American and Caribbean Center of information on Health Sciences, National Library of Medicine, United States and Scientific Electronic Library Online databases published on-line between 1992 and 2013 as well as theses and textbooks. Most studies have showed that the omission / reduction of insulin and eating disorders in type 1 diabetes were related to poor metabolic control, while binge eating in type 2 diabetes (with overweight or obesity) appears to be related to impaired physical health. There are several reports in which the type 2 diabetes associated with binge eating disorder have no influence on the results of Hemoglobin A, Glycosylated. Moreover, there is evidence of higher incidence of depression among diabetic patients, a fact that seems to be linked to changes in the clinical course of disease. The presence of comorbidities should be investigated such as eating disorders in Diabetes Mellitus patient, because together, disorders represent a problem in treating this group of patients, requiring a close eye on the preservation of adequate metabolic control and maintenance of quality of life of patients.

Validación de un punto de corte para la versión breve de la Escala de Depresión del Centro de Estudios Epidemiológicos en adultos mayores mexicanos / Validation of a cutoff point for the short version of the Depression Scale of the Center for Epidemiologic Studies in older Mexican adults

Objetivo. Identificar un punto de corte válido para la Escala de Depresión del Centro de Estudios Epidemiológicos (CES-D) de siete reactivos, que permita clasificar a los adultos mayores según presencia/ausencia de síntomas depresivos clínicamente significativos. Material y métodos. Estudio de tamizaje con 229 adultos mayores residentes de los estados de Morelos y Tlaxcala en México, que fueron parte de la muestra de la Encuesta Nacional de Salud y Nutrición, 2012. Se estimó la sensibilidad y especificidad asociada con el punto de corte seleccionado usando los criterios diagnósticos del ICD-10 (International Classification of Diseases, 10th revision) y del DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition). Resultados. El punto de corte estimado fue CES-D=5. De acuerdo con el ICD-10, los valores obtenidos de sensibilidad y especificidad fueron de 83.3 y 90.2%, y un valor ROC de 87% y, según el DSM-IV, los valores fueron 85, 83.2, y 84%, respectivamente. Conclusiones. La versión abreviada del CES-D puede ser utilizada como una prueba de tamizaje para identificar casos probables de adultos mayores con síntomas depresivos clínicamente significativos.

Objective. To identify a valid cutoff point associated with Center for Epidemiologic Studies, Depression Scale (CES-D) of seven items, which allows the classification of older adults according to presence/absence of clinically significant depressive symptoms. Materials and methods. Screening study with 229 older adults residing in two states of Mexico (Morelos and Tlaxcala), which were part of the sample from the National Survey of Health and Nutrition, 2012. We estimated the sensitivity and specificity associated with the selected cutoff points using the diagnostic criteria of ICD-10 (International Classification of Diseases, 10th revision) and DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, fourth edition). Results. The cutoff point estimated was CES-D=5. According to the ICD-10 sensitivity and specificity were 83.3 and 90.2%, and ROC was 87%. Using DSM-IV, the values were 85, 83.2, and 84%, respectively. Conclusions. The short version of the CES-D can be used as a screening test to identify probable cases of older adults with clinically significant depressive symptoms.

Validación de un punto de corte para la Escala de Depresión del Centro de Estudios Epidemiológicos, versión abreviada (CESD-7) / Validation of a cutoff for the Depression Scale of the Center for Epidemiologic Studies, Brief Version (CESD-7)

OBJETIVO: Evaluar las propiedades psicométricas de la Escala de Depresión del Centro de Estudios Epidemiológicos, versión abreviada (CESD-7) en población adulta mexicana y validar un punto de corte que permita clasificar a los sujetos según la presencia/ausencia de síntomas depresivos clínicamente significativos (SDCS). MATERIAL Y MÉTODOS: Estudio transversal de tamizaje en una submuestra de 301 adultos residentes del estado de Morelos en México, que fueron entrevistados originalmente para la Encuesta Nacional de Salud y Nutrición 2012. La sensibilidad y especificidad del punto de corte seleccionado se estimaron utilizando como referencia los criterios diagnósticos del ICD-10 y del DSM-IV. RESULTADOS: El punto de corte estimado fue CESD-7=9. Utilizando el ICD-10, los valores obtenidos de sensibilidad y especificidad fueron de 90.2 y 86%, y un valor receptor-operador (ROC) de 88%, y para el DSM-IV los valores encontrados fueron de 80.4, 89.6, y 85%, respectivamente. CONCLUSIONES: La versión abreviada del CESD-7 tiene buenas propiedades psicométricas y puede ser utilizada como una prueba de tamizaje para identificar casos probables de sujetos con síntomas depresivos clínicamente significativos.

OBJECTIVE: To evaluate the Depression Scale of the Center for Epidemiologic Studies, Brief Version (CESD-7) psychometric properties in Mexican adult population, and validate a cutoff for classifying subjects according to the presence / absence of clinically significant depressive symptoms (CSDS). MATERIALS AND METHODS: Screening cross-sectional study with a subsample of 301 adult residents of the Morelos state in Mexico, originally interviewed for the National Survey of Health and Nutrition 2012. Sensitivity and specificity of the selected cutoff were estimated using as reference the diagnostic criteria of ICD-10 and DSM-IV. RESULTS: The cutoff point estimated was CESD-7=9. Using the ICD-10 the sensitivity and specificity were 90.2 and 86%, and ROC was 88%. Using DSM-IV, the values were 80.4, 89.6, and 85%, respectively. CONCLUSIONS: The short version of the CESD-7 has good psychometric properties and can be used as a screening test to identify probable cases of subjects with clinically significant depressive symptoms.

Effectiveness of cognitive-behavioral therapy and amitriptyline in patients with chronic temporomandibular disorders: a pilot study

The aim of this pilot study was to evaluate the effectiveness of cognitive-behavioral therapy (CBT) and use of amitriptyline, a tricyclic antidepressant, in patients with chronic temporomandibular disorders (TMD). Forty-seven women (mean age = 35.4 years old) with chronic TMD were enrolled in the study and divided into 4 groups: amitriptyline; amitriptyline and CBT; placebo and CBT; and placebo only (control). Patients were managed for 7 consecutive weeks. Follow-up evaluations were done at the 1st, 7th and 11th weeks of treatment. The presence and severity of pain, levels of depression, and quality of life and sleep were measured. Data were analyzed using ANOVA, Chi-square and Cochran tests, considering a significance level of 5 percent. Improvements were found for all factors considered in the intragroup analysis, although no significant differences were detected among groups. However, at the end of the treatment (11 weeks of follow-up), these positive outcomes persisted only for the women treated with amitriptyline and CBT. The obtained results suggest that the combination of amitriptyline and CBT may be effective in reducing pain and depression levels as well as in improving the quality of life and sleep in patients with chronic TMD.

O objetivo deste estudo piloto foi avaliar a eficácia do uso de uma terapia cognitivo comportamental (TCC) e da amitriptilina, um antidepressivo tricíclico, no tratamento de pacientes portadores de disfunções temporomandibulares (DTM) crônicas. Quarenta e sete mulheres (com 35,4 anos em média) diagnosticadas com DTM crônica foram selecionadas e divididas em 4 grupos: amitriptilina; amitriptilina + TCC; placebo + TCC; e placebo (controle) e controle. As pacientes foram submetidas às terapias por 7 semanas consecutivas. As reavaliações aconteceram 1, 7 e 11 semanas após o início da terapia (11 semanas de avaliações). Foram avaliados a presença e severidade de dor, o nível de depressão, a qualidade de vida e do sono. Os dados foram avaliados através de ANOVA, Qui-quadrado e teste de Cochran, considerando um nível de significância de 5 por cento. Foram observadas melhoras significantes em todos os fatores avaliados para todos os grupos, porém não foram observadas diferenças entre os grupos. Após o final da terapia, os resultados positivos persistiram apenas para o grupo amitriptilina + TCC. Os resultados sugerem que o uso associado de amitriptilina e TCC no tratamento de pacientes portadores de DTM crônicas pode ser efetivo na melhora da dor, nível de depressão, qualidade de vida e do sono.

Un análisis epistemológico del diagnóstico de depresión / An epistemological analysis of the diagnosis of depression / Uma análise epistemológica do diagnóstico de depressão

The definition of the diagnosis of depression is analyzed based on the reflections of authors such as Canguilhem, Hacking and Pignarre. The present study does not deny the existence of concrete situations that might correspond to such diagnosis, but rather aims at carrying out a strictly epistemological analysis, however incomplete, of the way in which different aspects of this classification are validated and legitimized. First, based on Hacking's theorizations, the way in which human classifications are built is analyzed. Next, the epistemological fragility of the descriptive diagnosis of depression in the DSM-IV is pointed out, based on Canguilhem's concepts of normality and pathology. Finally, based on Pignarre's studies, some difficulties inherent in etiological explanations for this pathology are analyzed. It is possible to conclude that the alarming frequency of this diagnosis is associated with the epistemological fragility of that classificatory category.

Tomando como punto de partida las reflexiones de autores como Canguilhem, Hacking y Pignarre, se analiza la definición del diagnóstico de depresión. No se pretende negar la existencia de situaciones concretas que puedan corresponder a ese diagnóstico, sino realizar un análisis estrictamente epistemológico, y necesariamente incompleto, del modo como los diferentes aspectos de esta clasificación se validan y legitiman. En primer lugar se analiza, a partir de las teorizaciones de Hacking, de que modo se construyen las clasificaciones humanas. En segundo lugar, a partir de los conceptos de normalidad y patología de Canguilhem, se destacan algunas fragilidades epistemológicas del diagnóstico descriptivo de depresión presentes en el DSM-IV. Por fin, a partir fundamentalmente de los estudios de Pignarre, son analizadas algunas dificultades propias de las explicaciones etiológicas dadas a esa patología. Es posible concluir que la fragilidad epistemológica de esa categoría clasificatoria está directamente vinculada con la difusión de ese diagnóstico.

Tomando como ponto de partida as reflexões de autores como Canguilhem, Hacking e Pignarre, discute-se o diagnóstico de depressão. Não se pretende negar a existência de situações concretas que possam corresponder a esse diagnóstico, mas sim realizar uma análise estritamente epistemológica, e necessariamente incompleta, do modo como os diferentes aspectos desta classificação se validam e legitimam. Em primeiro lugar, se analisam, com base nas teorizações de Hacking, de que modo se constroem as classificações humanas. Em segundo lugar, com base nos conceitos de normalidade e patologia de Canguilhem, destacam-se algumas fragilidades epistemológicas do diagnóstico descritivo de depressão presentes no DSM-IV. Por fim, tomando por base os estudos de Pignarre, são analisadas algumas dificuldades próprias das explicações etiológicas dadas a essa patologia. É possível concluir que o alarmante crescimento desse diagnóstico está associado à fragilidade epistemológica dessa categoria classificatória.

Depressão maior suscita questionamento maior / Major depression invites major concerns

OBJETIVO: Revisar as limitações do conceito e do construto da depressão maior. MÉTODO: Os objetivos na conceitualização inicial da depressão maior são examinados em relação à sua subseqüente utilidade e relevância para os clínicos e pesquisadores. RESULTADOS: Afirma-se que, como definida, a depressão maior não diferencia bem a depressão clínica das expressões de depressão não clínica ou de tristeza; que seu conjunto de critérios não gera diagnósticos confiáveis; que um diagnóstico da depressão maior pouco significa por si só (na medida em que compreende efetivamente múltiplos tipos de depressão); e não nos informa sobre a causa, histórico natural ou resposta diferenciada ao tratamento. CONCLUSÃO: As limitações do conceito de depressão maior poderiam se beneficiar de uma avaliação mais ampla para impulsionar alterações no diagnóstico clínico dos subtipos depressivos.

OBJECTIVE: To overview limitations to the concept and construct of major depression. METHOD: The objectives in initially conceptualizing major depression are examined against its subsequent utility and relevance to clinicians and researchers. RESULTS: It is argued that, as defined, major depression does not differentiate clinical depression well from expressions of non-clinical depression or sadness, that its criteria set do not generate reliable diagnoses, that a diagnosis of major depression means little in and of itself (as it effectively comprises multiple types of depression) and that it fails to inform us about cause, natural history or differential treatment response. CONCLUSION: Limitations to the concept of major depression would benefit from wider appreciation to advance changes to the clinical diagnosis of depressive sub-types.

Prevalência de transtornos depressivos em pacientes submetidos à hemodiálise em dois serviços de nefrologia na cidade de criciúma / Prevalence of depressive disorders in pacients submitted to hemodyalisis in two nephorolgy services at Criciúma city

O objetivo desse trabalho foi avaliar a prevalência de transtornos depressivos em pacientes que se submetiamà hemodiálise em dois serviços de nefrologia na cidade de Criciúma. Conforme dados da literatura, a presençadesta morbidade é importante e merece ser reconhecida e tratada prontamente visto que a presença da mesma altera o prognóstico e a adesão ao tratamento. Aprevalência de depressão nessa população em específico é bastante variável, mas com certeza é bem maiorque na população em geral. Portanto, reconhecer a depressão, garantir e assegurar a integridade mental dessespacientes é muito importante durante o tratamento na hemodiálise.

The goal of this research was to evaluate the prevalence of depressive disorders in patients that were submittedto the hemodyalisis treatment in two services of nephrology at Criciúma city. In agreement with literatureresearches, the presence of this morbity is important and should be recognized as fast as possible and treated because the presence of this morbity can affect the prognostic and the adhesion to the treatment. The depression prevalence in this population in specific is too much variable, but it’s clear that it’s biggest that in general population. That’s way, to recognize the depression to guaranteeand to assure the mental integrity is very important during the hemodyalisis treatment.

Depresión: visión holística de la medicina interna / Depression: internal medicine holistic vision

La depresión, y la ansidad acompañante, es la manifestación psicológica más frecuente e intensa del sufrimiento humano, que en casos extremos termina en el suicidio. A pesar que puede restringir significativamente la calidad de vida del individuo, su interacción personal o social y productividad, sorprende que a nivel de la atención médica primaria no sea reconocida en la mitad de los casos y sea tratada en sólo la mitad de los diagnósticos. Sin embargo, es responsabilidad del médico internista estar preparado para reconocer la depresión y tratarla eficientemente, por las siguientes razones: 1. La medicina interna propone como concepción fundamental la visión integral del paciente; 2. El funcionamiento de la mente normal y patológica se fundamenta en principios biológicos; 3. La ansiedad y la depresión son las manifestaciones emocionales más frecuentes en la práctica médica, presentándose como desórdenes primarios o como condiciones asociadas a otros desórdenes psiquiátricos y enfermedades médicas (incluyendo a sus tratamientos), o que resultan del impacto emocional de las enfermedades médicas y quírurgicas. La referencia al psiquiatra debe hacerse en: depresión severa, respuesta terapéutica insatisfactoria, evidencia de psicosis o ideación suicida. En la depresión la herramienta básica es una relación médico-paciente solida, que garantice la integridad y la libertad del paciente y preserve el secreto profesional, que adquiere especial relevancia al abordar los sentimientos, las emociones y la conducta humana. Aunque útiles, las pruebas y escalas de la depresion no sustituyen a la entrevista personal con el paciente, que permite apreciar el ánimo depresivo y la anhedonia, resultantes de la desolación y el estado de indefensión que abruma al paciente. En la manía, extrema opuesto del espectro del animo, la agitación, el lenguaje expansivo y grandilocuente y la irritabilidad, pueden acompañar a la irracionalidad psicótica. La anormalidades de los neurotransmisores

Depression, and adjoined anxiety, is the most frequent and intense psychological manifestation of human suffering, which in extreme cases could lead to suicide. Even though it could affect significantly the quality of life, interpersonal and social interactions and individual productivity, it astonishes that at primary care, only half of the cases are diagnosed, and only half of those diagnosed are actually treated. However, it is the responibility of the Internist to recognize depression and treat it efficiently for the following reasons: 1. Internal medicine proposes the integral view of the patient as its fundamental conception; 2. Functioning of mind, both normal and pathological, is established in biological principles; 3. In medical practice, anxiety and depression are the most frequent emotional manifestations, either as primary disorders or as associated conditions to others psychiatric and medical diseases (including their treatments), or by the emotional impact of medical and surgical disorders. Psychitric referral should be made in severe depression, unsatisfactory therapeutic response and evidence of psychosis or suicidal ideation. In managing depression, a solid medical-patient relatioship is fundamental to guarantee patient liberty and integrity and to preserve professional secret, which acquires special relevance when dealing with human senses, emotions and behavior. Test and scales for depression, although useful, do not substitute the personal interview with patients that allow us to appreciate depressive mood and anhedonia, which result from the desolation and defenseless state that oppress the patient. In mania, opposite extreme of mood spectrum, the agitation, expansive and grandiloquent language as well as the irritability could be accompanied by psychotic irrationality. Abnormalities in norepinephrine and serotonin neutotransmitters play an important role in mood disorders, their levels and effects are less actives in depression

Depresión geriátrica y trastornos cognitivos / Geriatric depression and cognitive disorders

At the present, the depression constitutes one of the high-priority diseases in public health and frequently affects to the old people with chronic pathologies, mental deterioration and/or loss of functionality, causing suffering to the patient and family, as well as diminution in the functional capacity and worsening of the basic pathologies. The geriatric depression has symptoms that differentiate it from the depression of early onset, such as, less frequency of familiar antecedents and alterations of the personality, greater presence of psychotic and mental symptoms, greater association with cardiovascular risk factors and presence of comorbidities, as well as tendency to chronicity, delayed response to drugs, risk of relapses and/or of evolution to dementia. Given the important prevalence, the clinical course and the existence of subclinical symptoms of difficult detection, becomes necessary to incorporate to the daily practice, simple but effective tests of affective and mental evaluation with the purpose of to derive and/or to try, with pharmacological, rehabilitating and psychotherapeutic approaches.

La depresión, ¿una enfemedad o un síndrome? / Depression, disease or syndrome?

Depression seems to be heterogeneous in the clinic, laboratory finding g, prognosis, treatment and comorbidity. Today´s attitude of considering depression as one entity impresses as less then ideal, not permitting investigations to reach more uniform conclusions. The available literature on the symptomatic classifications of depression in analyzed. The findings strongly suggest that there are two types of clinical depression with peculiarities that identify them. It is advised to consider the clinical types both for clinical practice well as investigation.

La depresión parece ser un cuadro heterogéneo en la clínica hallazgos de laboratorio, pronóstico, tratamiento y comorbilidad. La actitud actual de considerarla una sola entidad impresiona como poco idónea y no permite que la investigación llegue a conclusiones más uniformes. Se analiza la literatura disponible acerca de las clasificaciones sintomáticas de los cuadros depresivos. Los hallazgos sugieren con fuerza que existe más de dos tipos clínicos de depresión con peculiaridad que los identifican. Se sugiere considerar los tipos clínicos tanto para investigación como en la práctica clínica habitual.

Depresión / Depression

La depresión es un estado psíquico de abatimiento, y a veces de postración, que suele acompañarse, en el aspectosomático, de astenia, es decir, de una flaqueza y debilidad más o menos acentuada. Por lo tanto la depresión esun estado psíquico en que están disminuidas las energías morales y físicas del individuo.

Factores de riesgo psicosocial, asociados a ansiedad y depresión en los trabajadores administrativos de una institución de educación superior en Pereira, 2003 / Psychosocial Risk Factors Associated with Anxiety and Depression in Administrative Workers in a Higher Education Institute in Pereira 2003

El objetivo de esta investigación fue establecer la asociación entre los factores de riesgo psicosocial inherentes al trabajo con depresión y ansiedad, en el área administrativa de una institución de educación superior en Pereira, segundo semestre de 2003, y recomendar estrategias de intervención de los riesgos psicosociales para mejorar la Salud Mental de los trabajadores a través del Área de Salud Ocupacional de la Institución. Se tomó el total de la población equivalente a 74 personas, con edades entre 17 y 61 años; nivel de escolaridad medio-alto, y una antigüedad laboral de 1 a 6 o más años. Se empleó una metodología de tipo descriptivo. Los instrumentos empleados fueron: la encuesta para la identificación de factores de riesgo psicosociales elaborada por Guillermo Bocanument Zuluaga y Norby Piedad Berján para el ISS, y la escala auto aplicada de Zung para depresión y ansiedad. Los resultados fueron analizados en el programa estadístico Epi Info versión 6.0, y en el análisis se encontró una relación entre el riesgo psicosocial carga mental y la ansiedad. El 10.7 por cien de la población se encontró con algún nivel de depresión o de riesgo de padecerla, y en el 20.3 por cien se halló algún nivel de ansiedad.

Depression in general clinical practice.

Worldwide currently about 340 million people suffer from depression. If not treated, it leads to increased morbidity and mortality. Risk factors include female sex, young age, lower socio-economic study, separated or divorced, positive family history, stressful life events, certain medical illness and so on. Aetiology lies on genetic factors, biochemical abnormality and personality and environmental factors. Clinical features lie on cardinal and other common symptoms. Depression usually starts before 40 years of age, average duration of one episode being 3-9 months. Treatment consists of a variety of psychotherapeutic approaches, pharmacotherapy and electroconvulsive therapy. A clinician may start therapy with low dose SSRIs which is considered as 1st line drugs. To educate patients about anti-depressants is very important.