Co-morbilidad neuro-psiquiátrica en infección por VIH / Neuropsychiatric comorbidity in HIV infection

Resumen Introducción: Aproximadamente 50% de las personas con infección por VIH padecen de alguna patología neuro-psiquiátrica. Características intrínsecas del virus, sus complicaciones, tratamiento y el contexto socio-cultural de los infectados facilitan el desarrollo de estas co-morbilidades, que determinan, en parte, el curso y pronóstico de las personas con infección por VIH. Objetivo: Introducir en la fisiopatología, características clínicas y manejo de la patología neuro-psiquiática en la infección por VIH, centrándose en dos de sus cuadros de mayor prevalencia: el trastorno neuro-cognitivo asociado al VIH (HAND) y el trastorno depresivo mayor (TDM). Desarrollo: En general, la detección y el tratamiento precoz de la patología neuropsiquiátrica en personas con infección por VIH mejora la calidad de vida de los pacientes, el curso clínico de la infección y mejora la adherencia al tratamiento anti-retroviral, lo que constituye una herramienta importante en el control de la propagación del VIH.

Abstract Background: The prevalence of neuropsychiatric disorders in HIV infected individuals is around 50%. Despite this, these diseases are often underdiagnosed and undertreated. Direct effects of the virus, opportunistic infections, adverse effects of antiretroviral therapy and the sociocultural context of the infected persons, contribute to the development of HIV associated neurocognitive disorder (HAND) and major depressive disorder (MDD), both of which have an impact in quality of life and disease progression. Aim: To introduce physicians in the pathophysiology, clinical features and management of psychiatric disease in seropositive patients. Content: Early detection and treatment of neuropsychiatric comorbidity in HIV infected individuals improve clinical outcomes, quality of life and is an important milestone in the control of the pandemic.

Prevalência de sonolência diurna excessiva e fatores associados em adolescentes da coorte RPS, em São Luís (MA) / Prevalence of excessive daytime sleepiness and associated factors in adolescents of the RPS cohort, in São Luís (MA), Brazil

RESUMO: Objetivos: Estimar a prevalência de sonolência diurna excessiva (SDE) e os fatores associados a ela em adolescentes da coorte de nascimentos de São Luís (MA). Método: Estudo transversal realizado com 2.514 adolescentes com idade de 18 e 19 anos. Utilizou-se abordagem hierarquizada e calculou-se a razão de prevalências utilizando regressão de Poisson com ajuste robusto da variância. Foram estudadas características sociodemográficas (sexo, cor, classe econômica, ocupação), hábitos de vida (lazer, fumo, álcool, uso de drogas ilícitas, consumo de café e de bebidas energéticas, prática de atividade física, adiposidade corporal, tempo de tela, depressão) e fatores relacionados ao sono. Resultados: A prevalência de SDE foi de 36,8%. Sexo feminino (razão de prevalência - RP = 1,33; intervalo de confiança de 95% - IC95% 1,19 - 1,49), alto risco de consumo de bebidas alcoólicas (RP = 1,26; IC95% 1,09 - 1,46), episódio depressivo maior atual (RP = 1,26; IC95% 1,08 - 1,46), escore de 10 a 18 de alterações do sono (RP = 1,43; IC95% 1,10 - 1,85) e escore de 5 a 7 da disfunção durante o dia (RP = 2,51; IC95% 2,06 - 3,07) foram os fatores de risco para SDE. A classe econômica D/E foi fator de proteção para SDE (RP = 0,47; IC95% 0,27 - 0,85). Conclusão: Mais de um terço dos adolescentes apresentou SDE, e aqueles com maiores riscos precisam melhorar seus hábitos de vida e de sono para que não tenham mais SDE, visando melhorar sua qualidade de vida.

ABSTRACT: Objectives: To estimate the prevalence and factors associated with excessive daytime sleepiness (EDS) in adolescents from the São Luís, Maranhão birth cohort. Method: Cross-sectional study conducted with 2,514 adolescents aged 18 and 19 years old. A hierarchical approach was used, and prevalence ratios were calculated using Poisson regression with robust variance adjustment. Sociodemographic characteristics (gender, race, economic class, and occupation), lifestyle (leisure activities, smoking, alcohol, illicit drug use, coffee and energy consumption, physical activity, body adiposity, screen time, and depression), and factors related to sleep were studied. Results: The prevalence of EDS was 36.8%. The female gender (PR = 1.33; 95%CI 1.19 - 1.49), high risk for alcohol consumption (PR = 1.26; 95%CI 1.09 - 1.46), current major depressive episode (PR = 1.26; 95%CI 1.08 - 1.46), sleep alteration score from 10 to 18 (PR = 1.43; 95%CI 1.10 - 1.85), and sleep score from 5 to 7 of daytime dysfunction (PR = 2.51; 95%CI 2.06 - 3.07) were risk factors for EDS. Economic class D/E was a protective factor for EDS (PR = 0.47; 95%CI 0.27 - 0.85). Conclusion: More than one-third of adolescents had EDS. Adolescents at higher risk need to improve their sleeping habits and lifestyle so that they no longer have EDS and can improve their quality of life.

Sociodemographic, behavioral, and health-related risk factors for depression among men and women in a southern Brazilian city

Objective: To assess the prevalence of depression and sociodemographic, behavioral, and health-related risk factors therefor in a southern Brazilian city. Methods: Population-based, cross-sectional study of adults from Rio Grande, state of Rio Grande do Sul, Brazil. Individuals (n=1,295) were selected using a multistage sampling procedure. The Patient Health Questionnaire-9 (PHQ-9) was used to screen for major depressive episodes (MDEs). We used a conceptual causal framework to organize and assess risk factors for MDE and calculated prevalence ratios (PR) using regression models. Results: The prevalence of MDE was 8.4% (95%CI 6.0-10.7) for men and 13.4% (95%CI 11.0-15.8) for women. For men, physical inactivity (PR 2.34, 95%CI 1.09-5.00) and perceived stress (PR 20.35, 95%CI 5.92-69.96) were associated with MDE. In women, MDE prevalence was higher among those in the first tertile of economic index (PR 2.61, 95%CI 1.53-4.45), with 0-8 years of schooling (PR 2.25, 95%CI 1.24-4.11), alcohol users (PR 1.91, 95%CI 1.21-3.02), those physically inactive (PR 2.49, 95%CI 1.22-5.09), with the highest perceived stress (PR 9.17, 95%CI 3.47-24.23), with another mental disorder (PR 1.85, 95%CI 1.32-2.59), and with more noncommunicable diseases (PR 1.85, 95%CI 1.06-3.22). Conclusion: Women had a higher prevalence of depression, and socioeconomic disadvantages were important for the occurrence of MDE; however, for men, only physical inactivity and stress were important predictors, suggesting possible different causal pathways for each sex.

Contextual risk factors of depression and suicidal thoughts in Brazilian adults: a multilevel analysis

Objective: To evaluate the association between social and health contextual variables, and between major depressive episodes (MDE) and suicidal thoughts in Brazilian adults. Methods: This population-based cross-sectional study used data from the 2013 National Health Survey (Pesquisa Nacional de Saúde). The Patient Health Questionnaire was used to evaluate the presence of MDE and suicidal thoughts. We used number of Family Health Strategy teams (FHS) per 20,000 state population, number of Psychosocial Care Centers (Centros de Atenção Psicossocial [CAPS]) per 1,000 state population, gross domestic product (GDP), and Gini index for each Brazilian state as contextual variables. Multilevel logistic regression models were used to calculate OR and the intraclass correlation coefficient (ICC). Results: Prevalence of MDE and suicidal thoughts was 4.1% (95%CI 3.8-4.4) and 3.8% (95%CI 3.5-4.1), respectively. Multilevel regression models showed an ICC of 1.1% for MDE (95%CI 0.5-2.3) and 1.3% for suicidal thoughts (95%CI 0.6-2.6). Neither GDP, Gini, FHS, or CAPS showed evidence of association with the outcomes. Conclusions: In general, contextual variables, within each Brazilian state, do not seem to affect the prevalence of MDE and suicidal thoughts.

Cognitive impairment and major depressive disorder in HIV infection and cerebrospinal fluid biomarkers / Alteracao cognitiva e desordem depressiva maior na infeccao do HIV e biomarcadores no liquido cefalorraquidiano

Cognitive impairment and major depressive disorder (MDD) are common HIV-1 central nervous system (CNS) complications. Their frequencies in AIDS patients are 36% and 45%, respectively. The diagnoses of HIV cognitive impairment are made by clinical criteria, no single laboratory test or biomarker establishes the diagnosis. Factors of indirect neuronal injury related with the pathophysiology of the HIV infection in the CNS, are the factors studied as biomarkers. In the present no biomarker is established to the diagnosis of HIV cognitive impairment, much still needs to be done. We review in this paper some biomarkers in cerebrospinal fluid that could be valuable to the diagnosis of HIV cognitive impairment. Diagnosing depression in the context of HIV can be challenging, to identify a biomarker that could help in the diagnosis would be very important, although MDD risks and neurobiology are still poorly understood.

A alteração cognitiva e a desordem depressiva maior (MDD) são complicações comuns da AIDS no sistema nervoso central (CNS). Suas frequências, em pacientes com AIDS são 36 % e 45 %, respectivamente. O diagnósticos de alteração cognitiva pelo HIV é feito por critérios clínicos, não há nenhum teste único de laboratório ou biomarcador que estabeleçam o diagnóstico. Os fatores inflamatórios relacionados com dano neuronal indireto e com a patofisiologia da infecção do HIV no CNS, são os fatores estudados como biomarcadores. No presente nenhum biomarcador é estabelecido para o diagnóstico de alteração cognitiva pelo HIV, muito ainda tem para ser feito. Nesta revisão abordaremos alguns biomarcadores no líquido cefalorraquidiano que podem auxiliar no diagnóstico da alteração cognitiva e HIV. Da mesma forma o diagnostico de depressão no contexto da aids pode ser desafiante, identificar um biomarcador que possa ajudar no diagnóstico seria muito importante, embora os riscos de desenvolvimento de MDD e a neurobiologia ainda sejam pobremente entendidos.

Factors associated with a diagnosis of major depression among HIV-infected elderly patients

Introduction Acquired immunodeficiency syndrome (AIDS) is being increasingly reported among the elderly and major depression (MD) may be associated with suboptimal adherence to treatment. Methods Cross-sectional study on factors associated with MD among 72 HIV-infected elderly individuals. Results Twenty (27.7%) patients were found to have MD. The female gender (odds ratio [OR] = 10.65; p = 0.00586), a low CD4 count during the study (OR = 1.005247; p = 0.01539), and current smoking status (OR = 12.89; p = 0.01693) were independently associated with MD. Conclusions Our data underscore the need to attentively search and treat MD among HIV-infected elderly patients. .

Climaterio: depresión y alteraciones del ánimo / Depression and climacteric

Hoy la depresión representa la primera causa de discapacidad en mujeres chilenas adultas. Si además consideramos el creciente número de mujeres que alcanza la menopausia, se hace evidente la necesidad de prevenir, diagnosticar y tratar las depresiones que se presentan en esta época de la vida. Recientemente, se sabe que la transición hacia la menopausia se asocia, no sólo a la posibilidad de que recidiven trastornos depresivos previos, sino también a una mayor propensión a desarrollar, por primera vez en la vida, una Depresión Mayor (OM). Mientras las alteraciones del ánimo se presentan en el 75 por ciento de las mujeres perimenopáusicas, la DM afecta al 16,6 por ciento de estas mujeres. En la etiología de estos trastornos influyen factores genéticos, hormonales, psicológicos y culturales. Si bien la terapia con estrógenos es una opción para tratar los síntomas depresivos leves que se presentan en mujeres menopáusicas, el consenso actual es que los antidepresivos son el tratamiento de elección para los episodios de OM que presentan estas mujeres.

Depression is nowadays the leading cause of disease burden in Chilean adult women. If the increasing number of women who reach the menopause is considered, the need to prevent, diagnose and treat depression presenting at this time of Ide becomes evident. Recently, it is known that the menopausal transition is associated not only to recurrence of previous depressive disorders but also to a higher risk of developing a major depressive episode (MO) for the first time in life. While mood alterations are present in 75 percent of perimenopausal women, MD affects 16,6 percent of these women. In the etiology of these disorders genetic, hormonal, psychological and cultural factors are influential. Although estrogen therapy is an option for treating mild depressive symptoms in menopausal women, present consensus is that antidepressants are the treatment of choice for episodes of MD in these women.

Prevalencia del Trastorno Obsesivo Compulsivo y su comorbilidad con el Trastorno Depresivo Mayor en adolescentes escolarizados / Prevalence of Obsessive Compulsive Disorder and its comorbidity with Major Depressive Disorder in adolescent students

Introducción: dos tercios de los adolescentes con Trastorno Obsesivo Compulsivo tienen otro diagnóstico psiquiátrico. El objetivo del estudio fue estimar la prevalencia del Trastorno Obsesivo Compulsivo y del Trastorno Depresivo Mayor en adolescentes escolarizados y su comorbilidad. Métodos: 390 adolescentes realizaron la entrevista clínica estructurada para los trastornos del Eje 1, módulos para Trastorno Obsesivo Compulsivo y Trastorno Depresivo Mayor. Examinamos los factores socio demográficos con análisis bivariado, estratificado y con regresión logística no condicional. Resultados: la prevalencia del Trastorno Obsesivo Compulsivo fue 7,63, la comorbilidad con depresión fue 48,27 y se encontró asociación entre los dos dos trastornos (RP 6,6 IC 3,45 - 12,61); la prevalencia de depresión fue 11,7; controlando variables confusoras en mujeres se observó que trabajar (RP 3,14), la edad (RP 1,45) Y tener trastorno depresivo mayor (RP 3,88), aumentan el riesgo de padecer de trastorno obsesivo compulsivo; en cambio en hombres solo el trastorno depresivo mayor mostró un mayor riesgo (RP 10,88). Conclusiones: la prevalencia del trastorno obsesivo compulsivo y trastorno depresivo mayor así como su comorbilidad en adolescentes escolarizados es alta; la edad de las adolescentes y el hecho de trabajar podrían ser un factor de riesgo en la presencia de Trastorno Obsesivo Compulsivo.

Introduction: at least two-thirds of the adolescents with Obsessive Compulsive Disorder have another psychiatric disorder. The objective of this study was to estimate the prevalence of Obsessive Compulsive Disorder and Major Depressive Disorder in adolescent students and its comorbidity. Methods: 390 adolescents were performed a structured clinical interview, clinical version: Obsessive Compulsive Disorder and Major Depressive Disorder modules. The inquired sociodemographic factors were analyzed with bivariate and multivariate statistical analysis and with non conditional logistic regression. Results: Obsessive Compulsive Disorder was 7.63, its comorbility with major depressive disorder was 48.27 and there was an association between both disorders (OR 6.6 IC 3.45 -12.61); Major Depressive Disorder prevalence was 1l.7; when we controlled confusing variables in women we found that work (OR 3,14), age (OR 1,45) and major depressive disorder (OR 3,88), showed higher risk of having Obsessive Compulsive Disorder; in contrast with the men just Major Depressive Disorder showed higher risk of having obsessive compulsive disorder (OR 10,88). Conclusions: the Obsessive Compulsive Disorder and Major Depressive Disorder prevalence and its association in adolescent students are high; age and work could be a risk factor of having Obsessive Compulsive Disorder.

Psychological consequences in pediatric intensive care unit survivors: the neglected outcome.

OBJECTIVES: To determine whether Pediatric Intensive Care Unit (PICU) hospitalization results in adverse psychological effects and to identify the contributory factors. SETTING: Level III PICU of a tertiary center. DESIGN: Prospective cohort study. METHODS: Consecutive patients 5 years or older admitted to PICU for at least 48 hours constituted the study population. Controls were age and sex matched children hospitalized in the pediatric wards for at least 48 hours. Severity of illness was assessed by the Pediatric Risk of Mortality (PRISM) score. Level of therapeutic intervention was determined by the Therapeutic Interventions Scoring System (TISS--76 score). Temperament Measurement Schedule was used to assess the premorbid temperament. Psychological assessment was performed using Impact of Event Scale (IES), Birleson Depression Scale and the Self-Esteem Scale. Follow-up evaluation was done one month after discharge. RESULTS: There were 30 children each in the study and control groups. They had comparable pre-morbid temperament as well as scores on the self-esteem and depression scales. Significantly higher proportion of patients in PICU had intrusive thoughts (43%) as compared to controls (6.7%). Development of intrusive thoughts correlated significantly with the degree of intervention. Demographic parameters, nature of the disease, duration of hospitalization and severity of illness did not correlate with the psychological outcome. One month after discharge, scores in both groups were comparable. CONCLUSIONS: Children subjected to therapeutic interventions in the PICU develop transient psychological impairment manifested by experiencing intrusive thoughts that resolve within a month.

Asimetrías funcionales frontales en el trastorno depresivo mayor / Functional frontal asymmetries in the depressive mayor disorder

Introducción: Las asimetrías funcionales de la corteza prefrontal son un importante parámetro predictor del estilo afectivo. Consecuentemente, diversos trastornos del afecto se asocian a diferencias individuales en dicho índice. En ese contexto, el trastorno depresivo mayor puede ser caracterizado por patrones anormales de activación de la corteza prefrontal izquierda. Material y métodos: Apoyados en los datos experimentales relevantes se presentan los fundamentos de un modelo del trastorno depresivo mayor que enfatiza los aspectos funcionales de la corteza cerebral. Conclusiones: Tanto el diagnóstico, como el tratamiento de la depresión dependen de nociones adecuadas de su etiología. Dada la heterogeneidad del paciente depresivo, así como los múltiples factores psicofisiológicos asociados, se propone una estrategia de investigación que considera marcadores objetivos para guiar el desarrollo de nuevos métodos de diagnóstico.

Síntomas depresivos posinfarto al miocardio: detección precoz en una población hospitalizada / Depressive symptoms after an acute myocardial infarction

Background: Depression after myocardial infarction (MI) is a frequent disorder and it increases the long-term risk of cardiac mortality. Aim: To assess the frequency of depressive symptoms and the history of depression in hospitalized post-MI patients. Patients and Methods: During three months, depressive symptoms and history of depression were studied in 47 consecutive patients (mean age 59,8±9,5 years, 68 percent male), admitted for MI to the Barros Luco Trudeau Hospital. The Beck Depression Inventory (BDI) and the Composite International Diagnostic Interview (CIDI 2.1) were used with DSM-IV diagnosis criteria. Results: According to the results obtained using the CIDI, 27,7 percent of the patients had a history of depression. This occurred in 53,3 percent of women and 15,6 percent of men (p <0.01). During the hospitalization, 38,3 percent of patients had depressive symptoms (BDI ³ 17 points), affecting 60 percent of women and 28,1 percent of men (p <0.02). In women and patients with history of depression, depressive symptoms tended to be more common and more severe. Conclusions: Depressive symptoms in post-MI patients are frequent and attending physicians should actively detect them.

Depressão pós-AVC: fatores de risco e terapêutica antidepressiva / Poststroke depression: risk factors and antidepressant treatment

A depressão é a complicação psiquiátrica mais freqüente nos pacientes com acidente vascular cerebral (AVC). Vários aspectos têm sido detectados como fatores de risco para a sua ocorrência. Neste artigo faz-se uma revisão dos fatores envolvidos na depressão pós-AVC e o estado atual de seu tratamento, a fim de estimular sua detecção e adequado tratamento pelo médico não-psiquiatra. A prevalência da depressão maior pós-AVC é de 10 por cento a 34 por cento, variando conforme as diferenças dos métodos de pesquisa. O período do pós-AVC, o tipo de população avaliada e o tratamento recebido pelos pacientes, assim como o critério utilizado para o diagnóstico da depressão, podem influir a sua prevalência. Fatores de risco associados à ocorrência da depressão pós-AVC têm sido detectados, tais como: prejuízo funcional, prejuízo cognitivo, história de depressão no passado, idade, sexo, AVC prévio, hipercortisolemia, precária rede de suporte social e características neuroanatômicas do AVC. Estes têm fornecido suporte para formulação de um mecanismo fisiopatológico da depressão pós-AVC, relacionado às vias prefrontosubcortical e à neurotransmissão das aminas biogênicas. As repercussões da depressão são significativas, incorrendo em um maior grau de prejuízo funcional, retardo do processo de reabilitação, complicações na evolução e maior risco de mortalidade. A isto se soma o seu subdiagnóstico e subtratamento. Com o advento da ressonância magnética, pesquisadores devem investigar a associação de regiões cerebrais específicas com a manifestação depressiva e resposta terapêutica. Aspectos metodológicos devem ser levados em consideração para uma análise mais confiável

El papel de la noradrenalina en la depresión / The role of noradrenaline in depression

A partir de las investigaciones realizadas en los años 60 y la respuesta terapéutica al tratamiento con antidepresivos tricíclicos se ha involucrado a la noradrenalina en la etiología del episodio depresivo mayor. La aparición de los inhibidores selectivos de la recaptación de serotonina, con igual eficacia y menor incidencia de efectos secundarios que los antidepresivos tricíclicos, impulsó y desarrolló las etiologías serotoninérgicas en los transtornos afectivos. Las investigaciones recientes y el diseño de moléculas antidepresivas, como la reboxetina, consideradas como inhibidoras selectivas de la recaptación de noradrenalina (NARI), han puesto de relieve nuevamente los aspectos noradrenérgicos en la etiología y terapéutica de los episodios depresivos. En el presente trabajo se revisan los aspectos biomoleculares, los modelos de investigación animal y la farmacodinámica de las nuevas moléculas antidepresivas, de tipo noradrenérgico

Percepción del cuidado parental en la depresión / Parental care perception in depression

En esta investigación se examina la percepción de cuidado parental como factor de riesgo en la depresión. Para ello hemos evaluado a 16 adultos, recuperados de un episodio único de un Trastorno Depresivo Mayor mediante EMBU ("Egna Minnen av Barndoms Oppfostran"), un instrumento sueco diseñado para evaluar la experiencia de cuidado parental y la calidad de relación con ambos padres en la infancia. Los resultados fueron comparados con los de un grupo control, pareado por edad, sexo, escolaridad y nivel socioeconómico. El grupo de pacientes depresivos percibía el cuidado parental recibido de sus padres como deficiente en calidez emocional, rechazante -sobre todo por parte del padre- y menos sobreproptector que el grupo de control. Las diferencias son estadísticamente significativas con niveles de confianza superiores al 95 por ciento. Los pacientes depresivos mostraban además una percepción más diferenciada de cada progenitor que el grupo de control. Los resultados son discutidos en el contexto de investigaciones que vinculan eventos tempranos con el desarrollo de psicopatología en la vida adulta. Nuestros datos apoyan las hipótesis que suponen una relación entre trastornos depresivos y deficientes experiencias de cuidado emocional en la infancia

Psicosis delirantes asociada a infección por el VIH / Delirious psychoses associated to VIH infection

SE presenta el informe de tres pacientes que presentaron Psicosis Delirantes en el curso de la infección por VIH (diagnosticados con técnica de Microelisa Positivo comprobado por Western Blot). Exponemos los cuadros psicóticos presentados los cuales son indistinguibles de la Psicosis Funcional que está descrita en la literatura. Dos de nuestros pacientes presentaron, después del grado psicótico, un deterioro cognitivo y uno no presentó deterioro cognitivo. Realizamos la discusión inclinándonos a plantear como agente etiopatológico el neurotropismo del virus, aunque sin dudas queda mucho por responder en el campo de la Neuropsiquiatría relacionada con esta enfermedad