Mental health help-seeking among Brazilian medical students: Who suffers unassisted?

INTRODUCTION: Several barriers for mental health help-seeking were identified among medical students, including minimizing mental illness. Studies examining aspects particular to those who perceive psychological impairment but do not access treatment are necessary for planning interventions. AIMS: To identify help-seeking barriers based on the students' perception about their need for treatment and psychiatric symptoms. Methods: Cross-sectional study assessing 436 Brazilian medical students (833 attending the medical school = 52.3% response rate). Data collection covered sociodemographic data, mental health, academic environment, and Beck Inventories of Depression (BDI) and Anxiety (BAI). Non-parametric tests and hierarchical logistic regression were used to compare students undergoing treatment, those willing to access treatment, and the ones reporting no need for treatment. RESULTS: Among the 382 students who completed the survey (87.6% completion rate), 38.5% (n = 147) were in treatment, and 33% (n = 126) were in need. Moderate to severe risk of alcohol abuse was observed in 45.9% (n = 50) of students reporting no need for treatment. Regression models suggested that perceiving need for treatment - whether already undergoing it or not - was associated with the severity of depressive symptoms (OR 1.14 [95% CI 1.07-1.21]), female assigned sex (OR 2.18 [95% CI 1.23-3.88]), LGBTQ+ (OR 2.47 [95% CI 1.09-5.60]) and reporting good relationship with the family (OR 0.26 [95% CI 0.08-0.83]). Models comparing students in treatment and those in need, pointed that the factors associated with lacking mental health care were age (OR 0.90 [95% CI 0.82-0.99]), perception of a heavy workload (OR 2.43 [95% CI 1.35-4.38]) and good relationship with colleagues (OR 3.51 [95% CI 1.81-6.81]). DISCUSSION: Social variables and the severity of depressive symptoms are positively associated with perceived need for treatment. Age and academic environment factors were related to help-seeking behavior among students with appropriate self-awareness. We discuss these findings' implications for planning interventions.

Work From Home or Bring Home the Work? Burnout and Procrastination in Brazilian Workers During the COVID-19 Pandemic.

OBJECTIVE: To investigate burnout and procrastination in a sample of Brazilian workers during the COVID-19 pandemic according to their current work mode. METHODS: This cross-sectional study used data from an online survey conducted in 2020: 435 workers were included. The Copenhagen Burnout Inventory and the Irrational Procrastination Scale were used to access burnout and procrastination respectively. RESULTS: There was no difference between workers working from home (WFH) and at face-to-face work regarding burnout symptoms. However, the WFH group had higher levels of procrastination. Clinically significant levels of burnout were associated with being female, increased childcare load and living with children under 12years old. CONCLUSIONS: WFH may have more advantages than disadvantages in ideal conditions. However, work-life imbalances seem to be a key aspect regarding distress among workers WFH, especially in women with small children.

Saúde mental dos profissionais da saúde na pandemia do coronavírus (Covid-19) / Mental health of health care professionals in the coronavirus pandemic (Covid-19)

Introdução: A pandemia do coronavírus (Covid-19) impôs desafios adicionais aos profissionais da saúde (PS), potencializando o risco de sofrimento psíquico. Objetivo: Avaliar o perfil sociodemográfico e a saúde mental de uma amostra de PS do Brasil durante a pandemia do Covid-19. Métodos: Estudo transversal online realizado durante 1 mês, entre maio e junho de 2020. Sintomas depressivos foram avaliados pelo Patient Health Questionnaire 9 (PHQ-9) e o nível de burnout pelo Copenhagen Burnout Inventory (CBI). Resultados: 1054 PS foram incluídos, sendo 34,5% médicos, 19,1% técnicos de enfermagem, 14,2% enfermeiros e 11,9% psicólogos. Mais da metade da amostra total apresentou escores ≥ 50 no domínio de burnout pessoal (PB) da CBI, indicativo de alto nível de burnout, e escores no PHQ-9 sugestivos de depressão clinicamente significativa, sendo estes índices mais elevados entre os técnicos de enfermagem (68,2% com PB ≥ 50 e 68,7% com PHQ-9 ≥ 9) e os PS da linha de frente (61,3% com PB ≥ 50 e 58% com PHQ-9 ≥ 9). Os técnicos de enfermagem apresentaram escores PB (58,4 ± 20,9) e do domínio de burnout relacionado ao trabalho (WB = 51,0 ± 21,1) superiores aos dos médicos (PB= 48,2 ± 19,9 e WB= 44,2 ± 19,1) e dos psicólogos (PB= 44,2 ± 17,4 e WB= 41,2 ± 16,7) p < 0,001. Conclusão: Os elevados níveis de burnout e depressão, mais preocupantes entre os técnicos de enfermagem, corroboram a vulnerabilidade dos PS ao sofrimento emocional no contexto do atendimento à Covid-19, demonstrando a urgência de intervenções específicas.(AU)

Introduction: The coronavirus pandemic (Covid-19) posed additional challenges to health care professionals (PS), increasing the risk of psychological distress. Objective: To evaluate the sociodemographic profile and mental health of a sample of PS in Brazil during the Covid-19 pandemic. Methods: Cross-sectional online study conducted during 1 month, between May and June 2020. Depressive symptoms were assessed by the Patient Health Questionnaire 9 (PHQ-9) and the level of burnout by the Copenhagen Burnout Inventory (CBI). Results: 1054 PS were included, being 34.5% physicians, 19.1% nursing technicians, 14.2% nurses and 11.9% psychologists. More than half of the total sample had scores ≥ 50 in the the personal burnout (PB) domain of CBI, indicative of a high level of burnout, and PHQ-9 scores suggestive of clinically significant depression, these rates being higher among nursing technicians (68.2% with BP ≥ 50 and 68.7% with PHQ-9 ≥ 9) and frontline PS (61.3% with BP ≥ 50 and 58% with PHQ-9 ≥ 9). Nursing technicians had PB scores (58.4 ± 20.9) and work-related burnout domain scores (WB = 51.0 ± 21.1) higher than those of physicians (PB = 48.2 ± 19.9 and WB = 44.2 ± 19.1) and psychologists (PB = 44.2 ± 17.4 and WB = 41.2 ± 16.7) p <0.001. Conclusion: The high levels of burnout and depression, most worrying among nursing technicians, corroborate the vulnerability of the PS to emotional suffering in the context of the Covid-19 pandemic. Specific interventions are urgent.(AU)

Introducción: La pandemia de coronavirus (Covid-19) planteó desafíos adicionales a los profesionales de la salud (PS), aumentando el riesgo de angustia psicológica. Objetivo: Evaluar el perfil sociodemográfico y la salud mental de una muestra de PS en Brasil durante la pandemia Covid-19. Métodos: Estudio transversal en línea realizado durante 1 mes, entre mayo y junio de 2020. Los síntomas depresivos fueron evaluados por el Patient Health Questionnaire 9 (PHQ-9) y el nivel de burnout por el Copenhagen Burnout Inventory (CBI). Resultados: Se incluyeron 1054 PS, siendo 34,5% médicos, 19,1% técnicos de enfermería, 14,2% enfermeras y 11,9% psicólogos. Más de la mitad de la muestra total tuvo puntajes ≥ 50 en el dominio de Burnout personal (PB) de CBI, indicativo de un alto nivel de Burnout, y puntajes PHQ-9 sugestivos de depresión clínicamente significativa, siendo estas tasas más altas entre los técnicos de enfermería (68,2% con PB ≥ 50 y 68,7% con PHQ-9 ≥ 9) y el PS de primera línea (61,3% con PB ≥ 50 y 58% con PHQ-9 ≥ 9). Los técnicos de enfermería tuvieron puntuaciones de PB (58,4 ± 20,9) y el dominio de burnout laboral (WB = 51,0 ± 21,1) superior al de los médicos (PB = 48,2 ± 19,9 y WB = 44,2 ± 19,1) y psicólogos (PB = 44,2 ± 17,4 y WB = 41,2 ± 16,7) p <0,001. Conclusión: Los altos niveles de burnout y depresión, que son más preocupantes entre los técnicos de enfermería, corroboran la vulnerabilidad del PS al sufrimiento emocional en el contexto de la atención al Covid-19, demostrando la urgencia de intervenciones específicas.(AU)

Brazilian Portuguese translation, cross-cultural adaptation, and apparent validation of the Trauma and Attachment Belief Scale.

OBJECTIVE: This article concerns the translation, cross-cultural adaptation, and apparent validation of the Trauma and Attachment Belief Scale (TABS), an instrument used to assess the psychological effects of traumatic life experiences and vicarious trauma. METHODS: This study involved literature review and evaluation of conceptual and item equivalences involving expert discussion groups focused on the existence and pertinence of the underlying theoretical concepts and corresponding items in a Brazilian context. Two translations and respective back-translations were performed during the evaluation of semantic equivalence, as well as an evaluation considering the referential and general equivalences between the original TABS and each version. Twenty-eight psychiatrists and psychologists completed a pretest. The final version was tested for reliability through the Cronbach's alpha and for verbal comprehension through the adapted verbal-numeric scale (ranging from 0 [I didn't understand anything] to 5 [I understood perfectly and I had no doubt]) in another 64 health professionals. RESULTS: The cross-cultural adaptation demonstrated high semantic equivalence for both the general (>95.0%) and the referential (>90.0%) meaning. The total Cronbach's alpha was 0.9173. All 84 items were maintained, and they favorably contributed to the internal consistency of the scale. The mean values of the adapted verbal-numeric scale for verbal comprehension obtained from health professionals varied from 4.2 to 4.9. CONCLUSION: The Brazilian version of the TABS demonstrated high-quality conceptual, item, and semantic equivalence with the original instrument, as well as high acceptability, internal consistency, and verbal comprehension. The scale is now available for use.

Brazilian Portuguese translation, cross-cultural adaptation, and apparent validation of the Trauma and Attachment Belief Scale / Tradução para o Português brasileiro, adaptação transcultural e validação aparente da Trauma and Attachment Belief Scale

Abstract Objective This article concerns the translation, cross-cultural adaptation, and apparent validation of the Trauma and Attachment Belief Scale (TABS), an instrument used to assess the psychological effects of traumatic life experiences and vicarious trauma. Methods This study involved literature review and evaluation of conceptual and item equivalences involving expert discussion groups focused on the existence and pertinence of the underlying theoretical concepts and corresponding items in a Brazilian context. Two translations and respective back-translations were performed during the evaluation of semantic equivalence, as well as an evaluation considering the referential and general equivalences between the original TABS and each version. Twenty-eight psychiatrists and psychologists completed a pretest. The final version was tested for reliability through the Cronbach's alpha and for verbal comprehension through the adapted verbal-numeric scale (ranging from 0 [I didn't understand anything] to 5 [I understood perfectly and I had no doubt]) in another 64 health professionals. Results The cross-cultural adaptation demonstrated high semantic equivalence for both the general (>95.0%) and the referential (>90.0%) meaning. The total Cronbach's alpha was 0.9173. All 84 items were maintained, and they favorably contributed to the internal consistency of the scale. The mean values of the adapted verbal-numeric scale for verbal comprehension obtained from health professionals varied from 4.2 to 4.9. Conclusion The Brazilian version of the TABS demonstrated high-quality conceptual, item, and semantic equivalence with the original instrument, as well as high acceptability, internal consistency, and verbal comprehension. The scale is now available for use.

Resumo Objetivo Este artigo se refere à tradução, adaptação transcultural e validação aparente da Trauma and Attachment Belief Scale (TABS), instrumento utilizado para avaliar os efeitos psicológicos das experiências de vida traumáticas e do trauma vicário. Métodos Este estudo envolveu uma revisão de literatura e avaliação da equivalência conceitual e dos itens, empregando grupos de discussão de especialistas, focando na existência e pertinência dos conceitos teóricos subjacentes e na correspondência dos itens dentro de um contexto brasileiro. Duas traduções e respectivas retrotraduções foram realizadas durante a avaliação da equivalência semântica, bem como foi feita uma avaliação considerando a equivalência referencial e geral entre a TABS original e cada versão. Vinte e oito psiquiatras e psicólogos completaram um pré-teste. A versão final foi testada para confiabilidade através do alfa de Cronbach e para compreensão verbal através de uma escala verbal-numérica adaptada [variando de 0 (Eu não entendi nada) a 5 (Eu entendi perfeitamente e não tive qualquer dúvida)] em outros 64 profissionais de saúde. Resultados A adaptação transcultural demonstrou alta equivalência semântica, tanto para o significado geral (>95,0%) quanto referencial (>90,0%). O alfa de Cronbach total foi de 0,9173. Todos os 84 itens foram mantidos e contribuíram favoravelmente para a consistência interna da escala. Os valores médios da escala verbal-numérica adaptada para a compreensão verbal obtidos dos profissionais de saúde variaram de 4,2 a 4,9. Conclusão A versão brasileira da TABS demonstrou equivalência conceitual, de itens e semântica de alta qualidade com o instrumento original, bem como elevada aceitabilidade, consistência interna e compreensão verbal. A escala está atualmente disponível para uso.

How do medical students defend themselves against anxiety?

OBJETIVO: A formação médica é geradora de ansiedade, tornando os estudantes de medicina vulneráveis a transtornos psiquiátricos, em particular os transtornos de ansiedade. Para lidar com a ansiedade o estudante de medicina lança mão de vários mecanismos de defesa. Objetivou-se avaliar a associação entre a presença de sintomas de ansiedade e o estilo defensivo em alunos de uma escola médica pública federal. MÉTODO: Trata-se de um estudo observacional transversal, de uma amostra de estudantes de medicina, do primeiro e sexto ano, devidamente matriculados e frequentando regularmente as aulas. No presente estudo utilizou-se um questionário sócio-demográfico, o Inventário Beck de Ansiedade e o questionário de estilo defensivo (DSQ-40). RESULTADOS: Responderam aos questionários 232 alunos, 110 do primeiro ano e 122 do sexto, representando 67,4% do total de alunos matriculados. Em relação aos mecanismos de defesa na amostra, as analises multivariadas mostraram que mecanismos de defesa neuróticos e imaturos estavam associados à presença de ansiedade (p < 0,001). CONCLUSÃO: Os dados encontrados no estudo apontam que alunos do curso médico que apresentaram sintomas de ansiedade utilizaram significativamente mais mecanismos de defesa neurótiocos e imaturos do que os que não tinham esses sintomas. Planos de prevenção, atenção e estratégias de apoio psicológico deveriam ser desenvolvidos para esse grupo, pois os mecanismos de defesa não parecem ser adaptativos em estudantes de medicina enfrentando ansiedade.(AU)

OBJECTIVE: Medical training is a generator of anxiety, making medical students vulnerable to psychiatric disorders. To deal with anxiety, medical students make use of several defense mechanisms. The aim was to assess the association between the presence of symptoms of anxiety and the defense style in students of a federal public medical school. METHOD: This is a cross-section observational study, of a sample of medical students, of the first and sixth years, duly enrolled and regularly attending classes. For the present study a socio-demographic questionnaire, the Beck Anxiety Inventory and the Defense Style Questionnaire (DSQ-40) were used. RESULTS: The questionnaires were answered by 232 students, 110 from the first year and 122 of the sixth year, representing 67.4% of the total amount of students. In relation to the defense mechanisms in the sample, the multivariate analysis showed that neurotic and immature defense mechanisms were associated with the presence of anxiety (p<0.001). CONCLUSION: The data found in this study indicate that medical students who showed symptoms of anxiety, used more neurotic or immature defense mechanisms than students who did not present these symptoms. Prevention and attention plans, as well as psychological support strategies should be developed for this group, because defense mechanisms do not appear to be adaptive in medical students experiencing anxiety.(AU)

Compreensão psicodinâmica do ciclo vital de Daenerys Targaryen, personagem da série Game of Thrones / Psychodynamic understanding of "Daenerys Targaryen's" life cycle, character from the series "Game of Thrones"

Este artigo analisa os aspectos psicológicos da personagem Daenerys Targaryen, da série Game of thrones, buscando essencialmente avaliar sua evolução cognitiva, social e comportamental, bem como os conflitos vivenciados em seu ciclo vital e os respectivos mecanismos de enfrentamento das adversidades. Por meio da interpretação subjetiva das simbologias metafóricas citadas na narrativa, extrapola-se a leitura literal da obra, com vistas a compreender também as representações da esfera inconsciente da personagem. Daenerys tem infância conturbada pela morte dos pais, pela fuga da cidade natal, pelo exílio e pelos maus-tratos cometidos pelo irmão. Ademais, são-lhe impostos casamento e erotização precoces, eventos que desrespeitam seu tempo de amadurecimento psíquico, desencadeando encurtamento das fases do seu ciclo vital e desestabilização do processo de latência e desenvolvimento puberal. Contudo, as experiências que vivencia no período, tais quais a gestação e a emancipação por que passa, associadas a variantes inatas da sua personalidade - a exemplo do temperamento dócil, inteligência e autoconfiança na capacidade de resolução de vicissitudes -, permitem a expressão de uma figura icônica de resiliência, com ativação de defesas maduras frente a crises vitais ou acidentais. O estudo permitiu discutir aspectos da realidade contemporânea do desenvolvimento humano e proceder à observação de diversos mecanismos de funcionamento psíquico, além da interação entre variantes intrínsecas e extrínsecas moduladoras da expressão de resiliência frente às dificuldades. Este artigo visa a contribuir para o estudo da teoria psicodinâmica e deve interessar a profissionais da medicina e da psicologia.(AU)

This article analyzes the psychological aspects of character Daenerys Targaryen, from Game of Thrones' series, seeking essentially to evaluate her cognitive, social and behavioral evolution, as well as the conflicts experienced to each stage of her life cycle and related adversity coping mechanisms. Through subjective interpretation of metaphoric symbols mentioned in the narrative, the literal reading of the story is extrapolated in order to also comprehend representations of the character's unconscious domain. Daenerys goes through a troubled childhood due to her parents' death, fleeing from her home city, exile and mistreatment committed by her brother. Furthermore, events like marriage and early erotization are imposed to her, which disrespect her psychic development timing, causing shortening of her life cycle's stages, and destabilization of the latency phase process and her pubertal development. Nevertheless, the experiences she goes through in this period, such as pregnancy and emancipation, associated to innate variants of her personality - docile temperament, high cognition and self-confidence in the ability of resolving difficulties -, allow the expression of a resilient iconic figure, with the activation of mature defenses when facing vital or accidental crises. The study allows transpositions to contemporaneous reality of human development and observation of several mechanisms of psychic functions, besides the interaction between intrinsic and extrinsic variants, which modulate the expression of resilience when confronting distress. It contributes to the study of psychodynamic theory and may be of interest to doctors and psychologists, especially those directly involved in psychic development.(AU)

Stress and coping in a sample of medical students in Brazil

Background Medical training is a stressing situation, making medical students vulnerable to psychiatric disorders, such as depression and anxiety. Objective The study aimed to assess the prevalence of stress and coping in students of a public medical school in Brazil, comparing the groups from the first and sixth years of training. Methods Through a cross-sectional, observational study, a sample of 232 first and sixth-year regularly registered medical students has been evaluated. Students filled a socio-demographic questionnaire, the Lipp Inventory of Stress Symptoms (ISSL), and the Coping Strategies Inventory (CSI). Results From the total sample of 232 students, 110 were first-year students and 122 sixth-year students. Stress symptoms were significantly higher in first-year students (49.1%) than in the sixth-year group (33.6%; p = 0.018). Variables significantly associated with stress were: year of the training (1st year > 6th year), income (lower > higher income), satisfaction with the training (dissatisfied > satisfied) and the use of escape/avoidance copying strategy (positive association). Discussion Considering the higher stress symptoms among first-year medical students and the positive association of the escape/avoidance copying strategy with stress, strategies must be developed to enable students starting medical school to be better at coping with this stressful situations.

First- and last-year medical students: is there a difference in the prevalence and intensity of anxiety and depressive symptoms?

Objective: Medical training is considered a significant stress factor. We sought to assess the prevalence and intensity of anxiety and depressive symptoms in medical students and compare samples of first-year and sixth-year students. Method: This was a cross-sectional study of first- and sixth-year medical students who attended classes regularly. The study instruments were a sociodemographic questionnaire, the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). Results: A total of 232 students (110 first-year, 122 sixth-year) completed the questionnaires, for a response rate of 67.4%. Overall 50.4% of respondents were male (56.4% of first-year and 45.1% of sixth-year students). Anxiety symptoms were reported by 30.8% of first-year students and 9.4% of sixth-year students (p < 0.001). Female students were more affected by anxiety. There were no significant between-group differences in depressive symptoms. Conclusion: A higher prevalence of anxiety symptoms was found in first-year medical students as compared with sixth-year students. Strategies should be developed to help medical students, particularly female students, manage these symptoms at the beginning of their medical training. .

First- and last-year medical students: is there a difference in the prevalence and intensity of anxiety and depressive symptoms?

OBJECTIVE: Medical training is considered a significant stress factor. We sought to assess the prevalence and intensity of anxiety and depressive symptoms in medical students and compare samples of first-year and sixth-year students. METHOD: This was a cross-sectional study of first- and sixth-year medical students who attended classes regularly. The study instruments were a sociodemographic questionnaire, the Beck Depression Inventory (BDI), and the Beck Anxiety Inventory (BAI). RESULTS: A total of 232 students (110 first-year, 122 sixth-year) completed the questionnaires, for a response rate of 67.4%. Overall 50.4% of respondents were male (56.4% of first-year and 45.1% of sixth-year students). Anxiety symptoms were reported by 30.8% of first-year students and 9.4% of sixth-year students (p < 0.001). Female students were more affected by anxiety. There were no significant between-group differences in depressive symptoms. CONCLUSION: A higher prevalence of anxiety symptoms was found in first-year medical students as compared with sixth-year students. Strategies should be developed to help medical students, particularly female students, manage these symptoms at the beginning of their medical training.

Therapeutic relationship on the web: to face or not to face? / Relação terapêutica na rede: to face or not to face?

In this age of unprecedented expansion of media and information dissemination and sharing, the use of electronic means should be reconsidered. The use of new technologies should be studied to understand how it may affect the relationship between patient and therapist during psychotherapy or psychoanalytic treatments. This study offers a critical discussion of the effect of technologies on clinical practice, and vignettes are used to describe their impact on frame, anonymity, abstinence and therapeutic neutrality. Transfer and countertransference issues resulting from these changes are also discussed. The potential benefits of new technologies in psychotherapy are appreciated, but the authors draw attention to the need to reflect about the presence of the therapist in those technologies and the preservation of the therapeutic setting, so that a satisfactory progression of the work of the dyad is ensured. This study also discusses the use of technologies in the expansion of learning and application of the therapeutic technique to overcome geographic and time barriers, among others (AU)

Na era da expansão sem precedentes dos meios de comunicação, da divulgação e compartilhamento de informações por meios eletrônicos, torna-se necessário repensar sua utilização. Os autores consideram importante compreender de que forma o uso das novas tecnologias pelos pacientes e terapeutas interfere na relação entre ambos na vigência do tratamento psicoterápico ou psicanalítico. É proposta uma discussão crítica acerca de sua influência na prática clínica, e apresentado em vinhetas o impacto no enquadre, no anonimato, abstinência e neutralidade terapêuticas. Também são abordadas questões transferenciais e contratransferenciais decorrentes dessas mudanças. Os autores consideram os benefícios potenciais das novas tecnologias na prática psicoterápica, alertando porém para a necessidade de reflexão a respeito de sua presença nas mesmas e de preservação do setting terapêutico, visando sempre a evolução satisfatória do trabalho da dupla. Outro aspecto considerado neste trabalho é sua utilização na expansão do aprendizado e aplicação da técnica psicoterapêutica, superando, entre outras, barreiras geográficas e temporais (AU)

Circulating omega-3 Fatty acids and neovascular age-related macular degeneration.

PURPOSE: We assessed the associations of serum, red blood cell membranes (RBCM) and dietary long-chain n-3 polyunsaturated fatty acids (LC-PUFAs) with neovascular age-related macular degeneration (AMD). METHODS: We included 290 patients of the Nutritional AMD Treatment 2 Study (NAT2) with neovascular AMD in one eye and early AMD lesions in the other eye, and 144 normal vision controls without AMD. Dietary intake of seafood was estimated by food frequency questionnaire. Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) composition in serum and RBCM were determined by gas chromatography from 12-hour fasting blood samples and was expressed as percentages of total fatty acids profile. Logistic regressions estimated associations of neovascular AMD with dietary intake of seafood and circulating n-3 LC-PUFAs. RESULTS: Dietary oily fish and seafood intake were significantly lower in AMD patients than in controls. After adjustment for all potential confounders (age, sex, CFH Y402H, ARMS2 A69S, and ApoE4 polymorphisms, plasma triglycerides, hypertension, hypercholesterolemia, and family history of AMD), serum EPA was associated significantly with a lower risk for neovascular AMD (odds ratio [OR] = 0.41; 95% confidence interval [CI], 0.22-0.77; P = 0.005). Analysis of RBCM revealed that EPA and EPA+DHA were associated significantly with a lower risk for neovascular AMD (OR = 0.25; 95% CI, 0.13-0.47; P < 0.0001 and OR = 0.52; 95% CI, 0.29-0.94; P = 0.03, respectively). CONCLUSIONS: The RBCM EPA and EPA+DHA, as long-term biomarkers of n-3 dietary PUFA status, were associated strongly with neovascular AMD and may represent an objective marker identifying subjects at high risk for neovascular AMD, who may most benefit from nutritional interventions. (http://www.controlled-trials.com/isrctn number, ISRCTN98246501).

Therapeutic relationship on the web: to face or not to face?

In this age of unprecedented expansion of media and information dissemination and sharing, the use of electronic means should be reconsidered. The use of new technologies should be studied to understand how it may affect the relationship between patient and therapist during psychotherapy or psychoanalytic treatments. This study offers a critical discussion of the effect of technologies on clinical practice, and vignettes are used to describe their impact on frame, anonymity, abstinence and therapeutic neutrality. Transfer and countertransference issues resulting from these changes are also discussed. The potential benefits of new technologies in psychotherapy are appreciated, but the authors draw attention to the need to reflect about the presence of the therapist in those technologies and the preservation of the therapeutic setting, so that a satisfactory progression of the work of the dyad is ensured. This study also discusses the use of technologies in the expansion of learning and application of the therapeutic technique to overcome geographic and time barriers, among others.

Abordagens ao cyberbullying / Approach to cyber bullying

Na atualidade, frente a tantos avanços tecnológicos, muitos pais, professores e diretores de escola se sentem despreparados para compreender e mesmo a responder ao cyberbullying. Podem não se sentir familiarizados com os termos cibernéticos ou estar convencidos de que nasceram em uma geração incapaz de saber quais comportamentos on-line atuais são apropriados. A intenção dos autores é contribuir para a discussão do tema, propor intervenções para combater o cyberbullying e propiciar novas compreensões para ajudar jovens, pais, professores e escola a lidar com esse problema, de forma neutra e sem juízo de valor.(AU)

Nowadays, with so many technological advances, many parents, teachers and school principals feel unprepared to understand and respond to cyberbullying. They may not feel familiar with cybernetic terms or are convinced they were born in a generation incapable of knowing which current online behaviours are appropriate. The authors aim at contributing to the discussion of the topic, propose interventions to combat cyberbullying and provide new understandings to help young people, parents, teachers and school to deal with this problem neutrally and non-judgmental.(AU)

Oral docosahexaenoic acid in the prevention of exudative age-related macular degeneration: the Nutritional AMD Treatment 2 study.

OBJECTIVE: To evaluate the efficacy of docosahexaenoic acid (DHA)-enriched oral supplementation in preventing exudative age-related macular degeneration (AMD). DESIGN: The Nutritional AMD Treatment 2 study was a randomized, placebo-controlled, double-blind, parallel, comparative study. PARTICIPANTS: Two hundred sixty-three patients 55 years of age or older and younger than 85 years with early lesions of age-related maculopathy and visual acuity better than 0.4 logarithm of minimum angle of resolution units in the study eye and neovascular AMD in the fellow eye. METHODS: Patients were assigned randomly to receive either 840 mg/day DHA and 270 mg/day eicosapentaenoic acid (EPA) from fish oil capsules or the placebo (olive oil capsules) for 3 years. MAIN OUTCOME MEASURES: The primary outcome measure was time to occurrence of choroidal neovascularization (CNV) in the study eye. Secondary outcome measures in the study eye were: incidence of CNV developing in patients, changes in visual acuity, occurrence and progression of drusen, and changes in EPA plus DHA level in red blood cell membrane (RBCM). RESULTS: Time to occurrence and incidence of CNV in the study eye were not significantly different between the DHA group (19.5±10.9 months and 28.4%, respectively) and the placebo group (18.7±10.6 months and 25.6%, respectively). In the DHA group, EPA plus DHA levels increased significantly in RBCM (+70%; P<0.001), suggesting that DHA easily penetrated cells, but this occurred unexpectedly also in the placebo group (+9%; P = 0.007). In the DHA-allocated group, patients steadily achieving the highest tertile of EPA plus DHA levels in RBCM had significantly lower risk (-68%; P = 0.047; hazard ratio, 0.32; 95% confidence interval, 0.10-0.99) of CNV developing over 3 years. No marked changes from baseline in best-corrected visual acuity, drusen progression, or geographic atrophy in the study eye were observed throughout the study in either group. CONCLUSIONS: In patients with unilateral exudative AMD, 3 years of oral DHA-enriched supplementation had the same effect on CNV incidence in the second eye as did the placebo. However, RBCM fatty acid measurements revealed that CNV incidence was significantly reduced in DHA-supplemented patients showing a steadily high EPA plus DHA index over 3 years. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found after the references.

Is it all grist to the mill? Wandering between indications for psychoanalytic treatment and the analytic field.

Determining the indications and contraindications for psychoanalytic treatment seems crucial to achieve therapeutic success and improve treatment effectiveness. In reviewing the classic literature on the topic, aspects such as age, diagnosis, motivation for treatment, present moment in life, ability to gain insight, psychic suffering when seeking treatment, defensive behaviors, and frustration tolerance are clearly analyzed by therapists/analysts when indicating psychoanalytic treatments. However, traditionally, most criteria underlying such indications date back to a time when the therapeutic relationship was viewed merely as a therapist treating a patient, with no regard to the therapeutic relationship itself. The goal of this article was to critically review the relevance and current adequacy of indications for psychoanalytic treatment, in view of advancements in knowledge on the analytic field. Considering cases that do not evolve as expected according to the indications, patients who are better suited to certain therapists, and therapist-patient pairs that modify their interaction over the course of treatment, the main question remains on how to identify the necessary elements in evaluating a candidate patient for psychoanalytic treatment, as well as the significant elements of therapeutic action.

Is it all grist to the mill? Wandering between indications for psychoanalytic treatment and the analytic field / Caiu na rede é peixe? Entre as indicações de tratamento psicanalítico e o campo analítico

Determining the indications and contraindications for psychoanalytic treatment seems crucial to achieve therapeutic success and improve treatment effectiveness. In reviewing the classic literature on the topic, aspects such as age, diagnosis, motivation for treatment, present moment in life, ability to gain insight, psychic suffering when seeking treatment, defensive behaviors, and frustration tolerance are clearly analyzed by therapists/analysts when indicating psychoanalytic treatments. However, traditionally, most criteria underlying such indications date back to a time when the therapeutic relationship was viewed merely as a therapist treating a patient, with no regard to the therapeutic relationship itself. The goal of this article was to critically review the relevance and current adequacy of indications for psychoanalytic treatment, in view of advancements in knowledge on the analytic field. Considering cases that do not evolve as expected according to the indications, patients who are better suited to certain therapists, and therapist-patient pairs that modify their interaction over the course of treatment, the main question remains on how to identify the necessary elements in evaluating a candidate patient for psychoanalytic treatment, as well as the significant elements of therapeutic action

Determinar critérios de indicação e contraindicação para tratamentos psicanalíticos parece um ponto técnico crucial para a obtenção de sucesso terapêutico e a elevação de seus índices de efetividade. Na revisão da literatura clássica sobre o tema, percebe-se que a idade, o diagnóstico do paciente, a motivação para tratamento, o momento de vida, a capacidade de insight, o sofrimento psíquico apresentado no momento da busca de tratamento, o estilo defensivo e a tolerância à frustração são alguns dos pontos analisados pelos terapeutas/analistas para indicar tratamentos psicanalíticos. Contudo, classicamente, tais indicações provêm de um período em que a relação terapêutica era vista meramente como um terapeuta atendendo um paciente, sem levar em conta a relação terapêutica propriamente dita. O objetivo deste artigo foi revisar criticamente a relevância e pertinência atual das indicações para tratamento psicanalítico, tendo em vista a evolução dos conhecimentos sobre o campo analítico. Considerando casos que não evoluem da maneira esperada segundo as indicações, pacientes que se adaptam melhor a determinados terapeutas e duplas que modificam sua interação ao longo do tempo de tratamento, a principal questão continua sendo como identificar quais seriam os elementos necessários na avaliação de um paciente candidato a tratamento psicanalítico, bem como os elementos significativos da ação terapêutica

A criança frente à doença e à morte: aspectos psiquiátricos / The child acing sickness and death: psychiatric aspects

O atendimento da criança com doença grave ou terminal é uma situação bastante delicada e complexa, que envolve questões psicológicas importantes do paciente, de sua família e de todos os envolvidos no seu cuidado. A partir da revisão das etapas evolutivas das crianças, este artigo tem o objetivo de auxiliar a identificar as reações que elas apresentam diante da sua própria doença e/ou morte, ilustrando com alguns exemplos clínicos. Destaca-se a importância da participação da consultoria psiquiátrica na internação hospitalar em pediatria, que pode ser requisitada para avaliar e/ou atender, do ponto de vista psiquiátrico, a criança portadora de doença grave ou terminal e, também, a família do paciente. Cabe ainda ao consultor psiquiátrico o desafio de proporcionar atenção à equipe assistente, visto que o estresse a que são submetidos os "profissionais da linha de frente" é de tamanha intensidade, que alguns autores o compararam ao vivido no campo de batalha. A busca de um conhecimento profundo sobre si mesmos e sobre os aspectos relacionados à doença e à natureza do paciente sob seus cuidados pode permitir que os profissionais de saúde se posicionem com tranquilidade diante de uma criança gravemente doente e sua família. Quaisquer decisões que venham a ser tomadas precisam estar de acordo com os princípios éticos que cada indivíduo adota, mas também de acordo com os princípios éticos vigentes na contemporaneidade.(AU)

The treatment of a severely or terminally ill child is a very complicated situation that involves psychological issues of great significance to the patient, the family and all those involved in their care. From the review of the child's developmental stages, this study aims to help identify their reactions in front of their illness or death, illustrating with some clinical examples. We highlight the importance of the participation of the psychiatric consultation service during pediatric hospitalization, since the terminally ill child, the family, or both, frequently need psychiatric assessment or attention. The psychiatrist also has the challenge of providing attention to the "front-line" healthcare team, since the stress they experience is such that some authors compare it to the stress experienced in the battle field. The search for a profound knowledge about themselves and aspects related to the disease and the nature of the patient under their care, may allow healthcare professionals to acquire a calm stance when facing severely ill children and their families. Any decisions taken should be in agreement with ethical principles, both those held by each individual and those prevailing in contemporary times.(AU)

A hipermodernidade e a clínica psicanalítica / Hypermodernity and the psychoanalytic clinic

A partir do conceito de hipermodernidade proposto por Lipovetsky, discute-se acerca das possíveis repercussões psíquicas dos movimentos e transformações sociais identificados pelo filósofo, bem como sobre os desafios que essas mudanças propõem à psicanálise nos dias atuais. Compreender as vicissitudes da cultura em que o sujeito está inserido instrumentaliza o terapeuta para analisar, com seu paciente, a forma como ele integra as demandas coletivas e próprias do seu tempo com suas necessidades individuais. O paciente hipermoderno nos interroga acerca das condições de intervenção psicanalítica possíveis nos dias de hoje. Suas queixas são diferentes daquelas direcionadas a Freud. É, portanto, fundamental que psicoterapeutas estejam em contato com essas novas construções sociais e mantenham uma postura continente e não apocalíptica.(AU)

From the hypermodernity concept proposed by Lipovetsky, some discussions can be placed on the possible psychological repercussion of movements and social transformations, identified by the philosopher, as well as, the challenges that they propose to psychoanalysis nowadays. Understanding the vicissitudes of the culture in which the subject is inserted, equips the therapist to analyze, together with his patient, the way how he integrates the collective and personal demands of his time to his individual needs. The hypermodern patient questions us regarding the possible psychoanalytic intervention conditions of our time. Their complaints are different to those directed at Freud. Therefore, it is vital that psychotherapists be in contact with these new social constructions and maintains a containing behavior which is not apocalyptic.(AU)