Correlates and prevalence of post-traumatic stress disorders in the São Paulo metropolitan area, Brazil.

BACKGROUND: Post-traumatic stress disorder (PTSD) is a debilitating condition, which generates an extensive burden. We aimed to investigate in a huge metropolitan area, the prevalence of traumatic experiences, the development of PTSD, and its predictors. METHODS: Traumatic experiences and PTSD were assessed in 5037 adult individuals of the general population. Cross-tabulations method assessed the prevalence of traumatic events and PTSD. Logistic regression models investigated predictors of lifetime and 12-month odds of PTSD and the conditional probability of developing PTSD for specific traumas. RESULTS: Lifetime and 12-month diagnoses of PTSD were found in 3.2% and 1.6% of the sample. 'Witnessing anyone being injured or killed, or unexpectedly seeing a dead body' (35,7%) and 'being mugged or threatened with a weapon' (34.0%) were the two most reported traumas. The commonest events before PTSD onset were 'sudden unexpected death of a loved one' (34.0%), 'interpersonal violence' (31.0%), and 'threats to the physical integrity of others' (25.0%). Experiences related to "interpersonal violence" presented the highest conditional probability for PTSD (range 2.2-21.2%). Being 'sexually assaulted or molested' (21.2% total; 22.3% women; 0.0% men) and being 'raped' (18.8% total; 18.4% women; 20.1% men) were the two experiences with the highest odds for PTSD. While being female was a predictor of less exposure to any event (OR = 0.69), females were more prone to develop lifetime PTSD after exposure to an event (OR = 2.38). CONCLUSION: Traumatic events are frequent in the general population and a small group of traumatic events accounts for most cases of subsequent PTSD.

Association between childhood adversities and psychopathology onset throughout the lifespan: Findings from a large metropolitan population.

BACKGROUND: Childhood adversities (ECA) are deleterious experiences that can occur during individuals' development, which has been associated with several negative health outcomes. AIM: Analyze the effect of ECA on the onset of DSM-IV disorders throughout life. METHOD: The Composite International Diagnostic Interview (CIDI) was used in a stratified, multistage area probability sample of 5037 individuals aged 18 or more to assess the presence of childhood adversities, 20 psychiatric disorders and their ages of onset. Discrete-time survival models were performed to estimate the odds of disorder onset. Data are from the São Paulo Megacity Mental Health Survey, the Brazilian branch of the World Mental Health Survey Initiative. FINDINGS: 53.6% of the sample experienced at least one ECA, and parental death (16.1%) and physical abuse (16%) were the most reported occurrences. Parental mental illness (OR = 1.99 to 2.27) and family violence (OR = 1.55 to 1.99) were the adversities most consistently associated with psychopathology across all age groups, while economic adversities (OR = 2.71 to 3.30) and parent criminality (OR = 1.72 to 1.77) were associated with psychopathology in individuals whose onset of disorder occurred from age 13 years on. Parental mental disorders and economic adversities were the strongest and most consistent predictors of all four classes of psychopathologies examined in multivariate models controlled for the clustering of adversities. Physical abuse was associated with externalizing disorders, while sexual abuse with internalizing disorders. INTERPRETATION: Childhood adversities were consistently associated with mental disorders. Economic adversities and parent mental disorders were predictive of psychopathology even if controlled for type (additive) and type and number of adversities (interactive models). Parental mental disorder and family violence were the main predictors of psychopathology onset across all age groups. Parental mental disorder was the only adversity that predicted all classes of disorders investigated.

The role of gender in the structure of networks of childhood adversity.

The objective of present study is to investigate the relationship between different childhood adversities. The potential impact of early adversity on prevention programs is discussed. Data on twelve childhood adversities was collected from a representative sample of 5037 members of the general population living in a large metropolitan area. Data were analyzed through network analysis, to estimate and compare network connectivity and centrality measures by gender. Over half the respondents had been exposed to at least one adversity during their earlier developmental stage. Among adversity-exposed persons, 48.4% presented simultaneous adversities, most of which were related to 'family dysfunction' and 'maltreatment' (mean = 2.9 adversities). Women reported more adversities than men (59.0% vs. 47.6%). Although the 'global' network connectivity across adversities was similar in both genders, 'regional' distinctions in the network structure were found. While 'neglect' and 'parental death' were more important for women than men, 'parental mental disorders' was more important for men. Gender-related childhood adversities were clustered experiences. Adversities related to 'early family dysfunction' and 'maltreatment' were prominent features in the networks of both boys and girls. Differential preventive and intervention programs should take into account gender-related patterns of exposure and reporting patterns of early adversity.

Gender-related patterns of psychiatric disorder clustering among bariatric surgery candidates: A latent class analysis.

BACKGROUND: Psychiatric disorders tend to distribute unevenly in women and men with severe obesity. The current research aimed to identify homogeneous clusters of concurrent psychiatric disorders among patients seeking bariatric surgery, by gender. METHODS: We recruited a consecutive sample of 393 candidates with obesity (311 women and 82 men) in a university-based bariatric center. Trained clinicians assessed psychiatric disorders through the Structured Clinical Interview for DSM-IV (SCID). Latent class analysis categorized pre-surgical patients into uniform clusters of co-occurring psychiatric disorders. RESULTS: For both genders, the 3-class psychopathological clustering was the best-fitting solution. Among women, the latent classes were: (1) "oligosymptomatic", wherein 42% of patients showed low probability of psychiatric disorders; (2) "bipolar with comorbidities", in 33%; and (3) "anxiety/depression", in 25%. Among men, (1) "bipolar with comorbidities" was found in 47% of patients; (2) "oligosymptomatic", in 40%; and (3) "anxiety/depression", in 13%. For both genders, the probability of presenting eating disorders was higher in both "bipolar" and "anxiety/depression" classes. Substance use disorders was prominent among "bipolar" men. In comparison with "oligosymptomatic" class, the likelihood of higher BMI was observed among "bipolar" men and poorer work attainment among men with "anxiety/depression". LIMITATION: Participants was cross-sectionally drawn from a single bariatric center. CONCLUSIONS: Pre-surgical men and women with severe obesity were distributed in three comorbidity profiles and revealed analogous psychopathological patterns. The class of "bipolar disorders" most likely presented comorbidity with eating and substance use disorder. This natural clustering of psychiatric disorders among bariatric patients suggests gender-related therapeutic approaches and surgical outcomes.

The epidemiology of personality disorders in the Sao Paulo Megacity general population.

INTRODUCTION: Most studies on the epidemiology of personality disorders (PDs) have been conducted in high-income countries and may not represent what happens in most part of the world. In the last decades, population growth has been concentrated in low- and middle-income countries, with rapid urbanization, increasing inequalities and escalation of violence. Our aim is to estimate the prevalence of PDs in the Sao Paulo Metropolitan Area, one of the largest megacities of the world. We examined sociodemographic correlates, the influence of urban stressors, the comorbidity with other mental disorders, functional impairment and treatment. METHODS: A representative household sample of 2,942 adults was interviewed using the WHO-Composite International Diagnostic Interview and the International Personality Disorder Examination-Screening Questionnaire. Diagnoses were multiply imputed, and analyses used multivariable regression. RESULTS AND DISCUSSION: Prevalence estimates were 4.3% (Cluster A), 2.7% (Cluster B), 4.6% (Cluster C) and 6.8% (any PD). Cumulative exposure to violence was associated with all PDs except Cluster A, although urbanicity, migration and neighborhood social deprivation were not significant predictors. Comorbidity was the rule, and all clusters were associated with other mental disorders. Lack of treatment is a reality in Greater Sao Paulo, and this is especially true for PDs. With the exception of Cluster C, non-comorbid PDs remained largely untreated in spite of functional impairment independent of other mental disorders. CONCLUSION: Personality disorders are prevalent, clinically significant and undertreated, and public health strategies must address the unmet needs of these subjects. Our results may reflect what happens in other developing world megacities, and future studies are expected in other low- and middle-income countries.

Morbidity persistence and comorbidity of mood, anxiety, and eating disorders among preoperative bariatric patients.

The current study investigates the patterns of disease persistence and comorbidity of psychiatric disorders among patients with class III obesity in pre-operative period. For 393 treatment-seeking patients with severe obesity recruited from a bariatric center, we ascertained their psychiatric diagnosis through Structured Clinical Interview for DSM-IV (SCID-I). Following, the frequency, persistence and comorbidity pattern of psychiatric disorders in this sample were determined. Current psychiatric disorders were observed in over half of patients during preoperative period, being anxiety disorders the most frequent diagnosis. For lifetime disorders, mood disorders were the most frequent diagnosis. Most of the sample presented 2 or more concurrent lifetime psychiatric disorders. While mood and eating disorders were frequent conditions, anxiety disorders were the most persistent conditions (the highest one month-to-lifetime prevalence ratio) and were significantly correlated with bipolar, depressive and eating disorders. Psychiatric disorders are frequent and enduring conditions among patients looking for bariatric surgery. Comorbid anxiety, mood, and eating disorders are remarkable features in treatment-seeking patients with obesity. Prognostic implications of preoperative psychiatric disorders on surgery outcome should be demonstrated prospectively in intervention studies.

Do Childhood Adversities Predict Suicidality? Findings from the General Population of the Metropolitan Area of São Paulo, Brazil.

BACKGROUND: Childhood adversities have been associated with a number of medical and psychiatric outcomes. However, the reported effects that specific childhood adversities have on suicidality vary across studies. METHOD: This was a cross-sectional, stratified, multistage area probability investigation of a general population in Brazil, designated the São Paulo Megacity Mental Health Survey. The World Mental Health Composite International Diagnostic Interview was applied in 5037 individuals ≥ 18 years of age, in order to assess 12 different adversities occurring during childhood and/or adolescence, as well as to look for associations between those adversities and subsequent suicidality in different age strata. RESULTS: Over half of the respondents reported at least one childhood adversity. Only physical abuse was consistently associated with suicide attempts in all subsequent life stages (OR = 2.1). Among adults 20-29 years of age, the likelihood of a suicide attempt was correlated with parental divorce, whereas suicidal ideation was associated with prior sexual abuse. Among adults over 30 years of age, physical illness and economic adversity emerged as relevant childhood adversities associated with suicide attempts, whereas sexual abuse, family violence, and economic adversity were associated with suicidal ideation. CONCLUSION: Childhood adversities, especially physical abuse, are likely associated with unfavorable consequences in subsequent years. For suicidality across a lifespan, the role of different childhood adversities must be examined independently.

The Influence of Parental Psychopathology on Offspring Suicidal Behavior across the Lifespan.

Suicide tends to occur in families, and parental psychopathology has been linked to offspring suicidal behaviors. This study explores the influence of parental mental disorders across the lifespan. Data are from the Sao Paulo Megacity Mental Health Survey, a cross-sectional household study with a representative sample of the adult population living in the Sao Paulo Metropolitan Area, Brazil (N=2,942). Survival models examined bivariate and multivariate associations between a range of parental disorders and offspring suicidality. After controlling for comorbidity, number of mental disorders and offspring psychopathology, we found that parental psychopathology influences suicidal behaviors throughout most part of the life cycle, from childhood until young adult years. Generalized anxiety disorder (GAD) and antisocial personality were associated with offspring suicidal ideation (OR 1.8 and 1.9, respectively), panic and GAD predicted suicidal attempts (OR 2.3 and 2.7, respectively), and panic was related to the transition from ideation to attempts (OR 2.7). Although noticed in many different stages of the lifespan, this influence is most evident during adolescence. In this period, depression and antisocial personality increased the odds of suicidal ideation (OR 5.1 and 3.2, respectively), and depression, panic disorder, GAD and substance abuse predicted suicidal attempts (OR varying from 1.7 to 3.8). In short, parental disorders characterized by impulsive-aggression and anxiety-agitation were the main predictors of offspring suicidality across the lifespan. This clinically relevant intergenerational transmission of suicide risk was independent of offspring mental disorders, and this underscores the need for a family approach to psychopathology.

Psychiatric disorders among obese patients seeking bariatric surgery: results of structured clinical interviews.

BACKGROUND: Obesity and psychiatric disorders are burdensome health problems commonly observed in general population and clinical samples. However, non-standardized assessment and small size of the sample might hamper conclusions of the investigations. The objective of this study is to replicate previous findings on frequency of psychiatric disorders and associated factors among obese patients seeking bariatric surgery, assessed through standardized interview. MATERIAL AND METHOD: The sample was comprised of 393 treatment-seeking obese patients (79.1% women; mean age 43.0 years, mean BMI 47.8 kg/m(2)) recruited from a university-based bariatric center. Trained clinicians ascertained the psychiatric diagnosis of the participants through structured clinical interview for DSM-IV Axis I diagnosis (SCID-I). RESULTS: The current rate of any psychiatric disorders was 57.8% (58.5% men vs. 57.6% women). The current anxiety disorders were the most frequent diagnosis (46.3%) among those participants with current disorder. Age and educational level were associated with the likelihood of presenting current psychiatric disorders. The lifetime rate of any psychiatric disorders was 80.9% (81.7 men vs. 80.7% women). Lifetime affective disorders were the most frequent diagnosis (total 64.9%; bipolar disorders 35.6% and depressive disorders 29.3%). About half of the sample presented 3 or more concurrent disorders among those respondents presenting any lifetime psychiatric disorders. CONCLUSIONS: Psychiatric disorders are frequent conditions among obese patients before bariatric surgery. Systematic assessment of patients in the pre-surgical phase is recommended. Prognostic implications of psychiatric disorders on surgery outcome should be demonstrated in follow-up study.

The influence of the comorbidity between depression and alcohol use disorder on suicidal behaviors in the São Paulo Epidemiologic Catchment Area Study, Brazil / Influência da comorbidade entre depressão e transtornos por uso de álcool nos comportamentos suicidas no Estudo de Área de Captação de São Paulo, Brasil

OBJECTIVE: To investigate in a community sample the association of suicide-related cognitions and behaviors ("thoughts of death", "desire for death", "suicidal thoughts", and "suicidal attempts") with the comorbidity of depressive disorders (major depressive episode or dysthymia) and alcohol or substance use disorders. METHOD: The sample was 1464 subjects interviewed in their homes using the Composite International Diagnostic Interview to generate DSM-III-R diagnosis. Descriptive statistics depicted the prevalence of suicide-related cognitions and behaviors by socio-demographic variables and diagnoses considered (major depressive episode, dysthymia, alcohol or substance use disorders). We performed a multivariate logistic regression analysis to estimate the effect of comorbid major depressive episode/dysthymia and alcohol or substance use disorders on each of the suicide-related cognitions and behaviors. RESULTS: The presence of major depressive episode and dysthymia was significantly associated with suicide-related cognitions and behaviors. In the regression models, suicide-related cognitions and behaviors were predicted by major depressive episode (OR = range 2.3-9.2) and dysthymia (OR = range 5.1-32.6), even in the presence of alcohol use disorders (OR = range 2.3-4.0) or alcohol or substance use disorders (OR = range 2.7-2.8). The interaction effect was observed between major depressive episode and alcohol use disorders, as well as between dysthymia and gender. Substance use disorders were excluded from most of the models. CONCLUSION: Presence of major depressive episode and dysthymia influences suicide-related cognitions and behaviors, independently of the presence of alcohol or substance use disorders. However, alcohol use disorders and gender interact with depressive disorders, displaying a differential effect on suicide-related cognitions and behaviors.

OBJETIVO: Investigar, numa amostra comunitária, a associação entre cognições e comportamentos relacionados ao suicídio ("pensamentos de morte", "desejo de morte", "pensamentos suicidas", e "tentativas de suicídio") e a comorbidade entre transtornos depressivos (episódio depressivo maior ou distimia) e transtornos por uso de álcool ou substâncias. MÉTODO: 1.464 sujeitos foram entrevistados em seus domicílios com o CIDI para gerar diagnósticos DSM-III-R. Estatística descritiva demonstrou a prevalência de cognições e comportamentos relacionados ao suicídio pelas variáveis sociodemográficas e diagnósticos considerados (episódio depressivo maior, distimia, transtornos por uso de álcool ou substâncias). Realizamos também análises de regressão logística multivariada para estimar o efeito da comorbidade entre episódio depressivo maior/distimia e transtornos por uso de álcool ou substâncias em cognições e comportamentos relacionados ao suicídio. RESULTADOS: A presença de episódio depressivo maior e distimia foi significativamente associada a cognições e comportamentos relacionados ao suicídio. Em modelos de regressão multivariada, os preditores de cognições e comportamentos relacionados ao suicídio foram episódio depressivo maior (OR range = 2,3-9,2) e distimia (OR range = 5,1-32,6) mesmo na presença de transtornos por uso de álcool (OR range = 2,3-4,0) ou transtornos por uso de substâncias (OR range = 2,7-2,8). O efeito de interação foi observado entre episódio depressivo maior e transtornos por uso de álcool, bem como entre gênero e distimia. Transtornos por uso de álcool foi excluído da maioria dos modelos. CONCLUSÃO: A presença de episódio depressivo maior e distimia influencia os CCS, independentemente da presença de transtornos por uso de álcool ou substâncias. Contudo, transtornos por uso de álcool e gênero interagem com os transtornos depressivos, demonstrando um efeito diferencial em cognições e comportamentos relacionados ao suicídio.

The influence of the comorbidity between depression and alcohol use disorder on suicidal behaviors in the São Paulo Epidemiologic Catchment Area Study, Brazil.

OBJECTIVE: To investigate in a community sample the association of suicide-related cognitions and behaviors ("thoughts of death", "desire for death", "suicidal thoughts", and "suicidal attempts") with the comorbidity of depressive disorders (major depressive episode or dysthymia) and alcohol or substance use disorders. METHOD: The sample was 1464 subjects interviewed in their homes using the Composite International Diagnostic Interview to generate DSM-III-R diagnosis. Descriptive statistics depicted the prevalence of suicide-related cognitions and behaviors by socio-demographic variables and diagnoses considered (major depressive episode, dysthymia, alcohol or substance use disorders). We performed a multivariate logistic regression analysis to estimate the effect of comorbid major depressive episode/dysthymia and alcohol or substance use disorders on each of the suicide-related cognitions and behaviors. RESULTS: The presence of major depressive episode and dysthymia was significantly associated with suicide-related cognitions and behaviors. In the regression models, suicide-related cognitions and behaviors were predicted by major depressive episode (OR=range 2.3-9.2) and dysthymia (OR=range 5.1-32.6), even in the presence of alcohol use disorders (OR=range 2.3-4.0) or alcohol or substance use disorders (OR=range 2.7-2.8). The interaction effect was observed between major depressive episode and alcohol use disorders, as well as between dysthymia and gender. Substance use disorders were excluded from most of the models. CONCLUSION: Presence of major depressive episode and dysthymia influences suicide-related cognitions and behaviors, independently of the presence of alcohol or substance use disorders. However, alcohol use disorders and gender interact with depressive disorders, displaying a differential effect on suicide-related cognitions and behaviors.

Residência em psiquiatria no Brasil: análise crítica / Brazilian psychiatry medical residency programs: critical analysis

INTRODUÇÃO: A psiquiatria evoluiu muito nas últimas décadas e seu estudo tornou-se, conseqüentemente, mais complexo. Os avanços em neurociências, aliados aos estudos clássicos de psicopatologia, psicofarmacologia, psicoterapia e neurologia, influenciaram grandemente o diagnóstico e o tratamento psiquiátricos. Apesar disso, a residência em psiquiatria no Brasil não se adequou a essa nova realidade. OBJETIVOS E MÉTODO: Partindo das recomendações da World Psychiatry Association (WPA), pesquisamos na Internet programas de residências brasileiros e de países das Américas e Europa. Comparamos nosso programa com as recomendações e dados do Institutional Program on the Core Training Curriculum for Psychiatry da WPA e propusemos um currículo mínimo para a residência em psiquiatria. DISCUSSÃO: Na maioria dos programas pesquisados, alguns pontos se destacam: duração mínima de 3 anos; estágio integral em neurologia por no mínimo um mês; conteúdo programático contendo psicopatologia, psicofarmacologia, teorias psicoterápicas, emergências psiquiátricas entre outras disciplinas; ensino e prática das diversas linhas psicoterápicas; abrangência das várias etapas da vida (crianças, adultos e idosos); álcool e drogas; espaços livres de que o residente pode dispor para sua formação (terapia, estudo ou pesquisa). CONCLUSÃO: O modelo brasileiro de residência em psiquiatria encontra-se defasado em relação à formação proposta pela WPA (observada em diversos países, mesmo latino-americanos). A residência necessita, seguindo modelo referenciado pela WPA e respeitando as diferenças regionais de cada escola, prover o mínimo para uma boa formação do psiquiatra.

Cisto ósseo aneurismático / Aneurysmal bone cysth

O presente estudo teve como objetivo analisar 27 portadores de cisto ósseo aneurismático, que foram tratados, respectivamente, no Hospital do Cancêr de Pernambuco e no Hospital das Clínicas da Universidade Federal de Pernambuco, entre 1995 e 2000. Dezesseis pacientes eram do sexo feminino e 11 do masculino, com uma média de idade de 19,7 anos. Os pacientes foram acompanhados por um período médio de 22 meses, mínimo de um e máximo de 57 meses. A principal localização foi no fêmur e, seguidamente, na tíbia. Os tratamentos foram: curetagem, eletrocauterização e preenchimento de cavidade com cimento acrílico (PMMA), ressecção ampla, ressecção com substituição por enxerto ou endoprótese, embolização e preeenchimento da cavidade por ciano-acrilato. Vinte e três pacientes foram curados com apenas uma intervenção, em um paciente foi realizada amputação primária; três necessitaram de um segundo tempo cirúrgico para amputação devido à recidiva com invasão do pedículo váculo-nervoso. As complicações decorrentes do tratamento foram: uma lesão temporária do nervo radial, um hálux valgo e uma artrose por comprometimento da superfície articular