Third Argentine Consensus statement on management Bipolar Disorders. Section3: Bipolar Disorder in the context of special situations / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Tercera parte: Manejo de los Trastornos Bipolares en el contexto de situaciones especiales.

This document constitutes the third and last part of the Third Argentine Consensus on the Management of Bipolar Disorders carried out by the Argentine Association of Biological Psychiatry (AAPB). Continuing with the initial objective, this section of the Consensus on the Management of Bipolar Disorders is focused on the management of bipolar disorders in special populations. This section constitutes a comprehensive review and expert consideration of the scientific evidence on: a) the management of bipolar disorders in treatment-resistant patients; b) the management of bipolar disorder in childhood and adolescence; c) the management of bipolar disorders in women during their perinatal period and, d) the management of bipolar disorders in older adults.

Este documento constituye la tercera y última parte del Tercer Consenso Argentino sobre el Manejo de los Trastornos Bipolares llevada a cabo por la Asociación Argentina de Psiquiatría Biológica (AAPB). Siguiendo con el objetivo propuesto por el comité de expertos, en la actual versión del Consenso sobre el manejo de los trastornos bipolares, esta sección está enfocada al abordaje de los Trastornos Bipolares en situaciones especiales. Esto configura una revisión exhaustiva de la evidencia científica  sobre: a) el manejo de los trastornos bipolares en pacientes resistentes al tratamiento, b) el manejo de los trastornos bipolares en la mujer en el período perinatal, c) el manejo del trastorno bipolar en la etapa infantojuvenil y d) el manejo de los trastornos bipolares en los adultos mayores.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 B / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Segunda Parte B.

This document constitutes the second section B of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The scope of this section is to provide therapeutic recommendations for managing bipolar disorders in adults, (i) acute mania (ii) bipolar depression (iii) mixed stated (iv) suicidality and (vi) psychological interventions. In addition, the current manuscript outlines the assessment and management of side effects of pharmacotherapeutic treatments.

Este documento constituye la segunda parte B del Tercer Consenso Argentino sobre el Manejo de los Trastornos Bipolares llevada a cabo por la Asociación Argentina de Psiquiatría Biológica (AAPB). Siguiendo con el direccionamiento iniciado en el parte 2A sobre el tratamiento integral de los trastornos bipolares, esta sección se ha enfocado en sintetizar la evidencia más actualizada sobre abordajes terapéuticos para pacientes adultos. El alcance de esta sección es proporcionar recomendaciones terapéuticas para el manejo de los trastornos bipolares en adultos, (i) manía aguda, (ii) depresión bipolar, (iii) estado mixto, (iv) el suicidio en el trastorno bipolar, (v) intervenciones psicológicas. Además, el presente manuscrito aborda la evaluación y el manejo de los efectos secundarios de los tratamientos farmacoterapéuticos.

Third Argentine Consensus statement on management Bipolar Disorders. Section 2 A: Comprehensive treatment of the bipolar disorders in adults / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Segunda Parte A: Tratamiento integral de los trastornos bipolares en el adulto.

This document constitutes the second section A of the Third Argentine Consensus on the Management of Bipolar Disorders, focused on synthesizing the most updated evidence on therapeutic approaches for adult patients. The aim of this section (2A) is to provide therapeutic recommendations for managing bipolar disorders in adults. In addition, the scope of this current manuscript outlines recommendations on the use of treatment guidelines, levels of evidence available to support these recommendations, general considerations for the treatment of bipolar disorders, the so-called pseudoresistance and adherence to treatment, general considerations on psychological therapies, as well as long term treatment of bipolar disorders.

Este documento corresponde a la segunda parte del Tercer Consenso Argentino sobre el manejo de los trastornos bipolares, enfocada en sintetizar la evidencia actualizada sobre los abordajes terapéuticos de esta patología en los pacientes adultos. Siguiendo la metodología descripta en la primera parte del Consenso, el panel de expertos realizó una exhaustiva revisión de la bibliografía y, como consecuencia de un posterior debate sobre la información disponible, se generó esta sección A del segundo documento que abarca el tratamiento integral de las personas adultas que padecen este trastorno. Durante la etapa de debate y discusión de estas guías, se decidió incorporar algunos puntos que estimamos serán de gran utilidad para el equipo interdisciplinario encargado del manejo de pacientes con trastornos bipolares.  En tal sentido, en la sección A de la segunda parte de este documento, se podrán encontrar las recomendaciones generales para el uso de las guías de tratamiento, los niveles de evidencia disponibles para sustentar las recomendaciones, las consideraciones generales del tratamiento de los trastornos bipolares, el fenómeno de pseudorresistencia y adherencia al tratamiento, las consideraciones generales sobre el abordaje psicológico, así como el tratamiento a largo plazo de los trastornos bipolares.

Third Argentine Consensus statement on management Bipolar Disorders. Section1: introduction and general concepts / Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares. Primera Parte: introducción, método de trabajo y generalidades.

The Third Argentine Consensus on the management of bipolar disorders (TB) is an initiative of the Argentine Association of Biological Psychiatry (AAPB). As a reference document, this consensus pursues two main objectives: on the one hand, to summarize and systematize the best available evidence on the comprehensive management of this pathology; on the other, to provide a useful, up-to-date instrument for psychiatrists, multidisciplinary teams dedicated to mental health, and government agencies. During a period of approximately six months of work -that is, from May to October 2022- a committee of experts made up of 18 professionals and representatives of the three most important Psychiatry and Mental Health associations in Argentina (that is, the AAPB, the Argentine Association of Psychiatrists, AAP, and the Association of Argentine Psychiatrists, APSA) have focused on updating the information regarding TB. Finally, this document was prepared as a result of an exhaustive review of the bibliography published to date, which was strategically divided into three parts: the first deals with the generalities of TB; the second deals with the comprehensive treatment of the pathology; finally, the third analyzes TB in the context of special situations.

El Tercer Consenso Argentino sobre el manejo de los Trastornos Bipolares (TB) es una iniciativa de la Asociación Argentina de Psiquiatría Biológica (AAPB). Como documento de referencia, este consenso persigue dos objetivos principales: por un lado, resumir y sistematizar la mejor evidencia disponible sobre el manejo integral de esta patología; por el otro, proporcionar un instrumento útil y actualizado a psiquiatras, a equipos multidisciplinarios abocados a la salud mental y a organismos gubernamentales. Durante un período de aproximadamente seis meses de trabajo -desde mayo a octubre de 2022- un comité de expertos integrado por 18 profesionales y por representantes de las tres asociaciones de Psiquiatría y Salud Mental más importantes de la Argentina: la AAPB, la Asociación Argentina de Psiquiatras, (AAP) y la Asociación de Psiquiatras Argentinos (APSA), se abocaron a actualizar la información respecto de los TB. Finalmente, y como resultado de una exhaustiva revisión de la bibliográfica publicada hasta la actualidad, se confeccionó este documento que fue dividido estratégicamente en tres partes: la primera versa acerca de las generalidades del TB; la segunda aborda el  tratamiento integral de la patología; y, por último, la tercera analiza los TB en el contexto de situaciones especiales.

Effectiveness of agomelatine on anhedonia in depressed patients: an outpatient, open-label, real-world study.

OBJECTIVE: The aim of this real-world study was to evaluate the effect of agomelatine on anhedonia as primary endpoint in outpatients under treatment of major depressive episodes. METHODS: The study was an open-label, multicenter, 8-week phase IV trial. Two hundred fifty-seven (257) patients were recruited, and 143 patients were included in the analysis. Agomelatine was administered orally as a 25-mg tablet. The dose could be increased to 50 mg after 2 weeks of treatment. RESULTS: An improvement in the severity of anhedonia (Snaith-Hamilton Pleasure Scale total score) was observed from 8.5 points at baseline to 4.1 at week 8, statistically significant (p < 0.05) from the first week. Significant decreases in scores on the severity of depression (Quick Inventory of Depressive Symptomatology 16-item Self-Report [QIDS-SR-16]), anxiety (Generalized Anxiety Disorder 7-item scale), and in overall clinical status (CGI) were also found over 8 weeks, independently from the presence of a first or recurrence episode. Response (QIDS-SR-16 score ≥ 50% of baseline) at week 8 was observed in 65.7% of the patients, while 49.6% of the patients achieved remission (QIDS-SR-16 score ≤ 5). CONCLUSION: Agomelatine was shown to be effective on anhedonia, depression, and anxiety in subjects with major depression. The pragmatic design of the study reflects real-world clinical practice providing interesting insights into routine care management.

Teoría de la mente y funcionalidad en pacientes bipolares en remisión sintomática / Theory of mind and functionality in bipolar patients with symptomatic remission

Introducción. Los déficits en la funcionalidad son comunes durante la remisión en el trastorno bipolar (TB). Adicionalmente, existe evidencia de alteraciones en la cognición social en remisión clínica. Estos déficits podrían contribuir a la disfunción observada en estos pacientes. Material y métodos. Doce pacientes bipolares en remisión sintomática (7 bipolares tipo i y 5 de tipo ii) y 12 individuos controles sin patología psiquiátrica completaron el Test de las Miradas y el Test de Faux Pas para evaluar teoría de la mente (ToM), y el Test Breve para la Evaluación de la Funcionalidad (FAST). Resultados. El desempeño de los pacientes bipolares en el aspecto cognitivo de la ToM se ubicó por debajo de la línea de corte, sin llegar a presentar diferencias significativas en comparación con el grupo control (p=0,078) y con tendencia a un peor desempeño a mayor número de episodios depresivos (p=0,082). Las puntuaciones medias para el componente emocional de la ToM se encontraron por encima de la puntuación de corte en ambos grupos. La funcionalidad global resultó significativamente inferior en los pacientes bipolares en comparación con la muestra control (p=0,001). A la vez, se observaron diferencias significativas entre ambos grupos en 5 de las 6 dimensiones del funcionamiento evaluadas. No se hallaron correlaciones significativas entre la ToM y la funcionalidad. Conclusiones. Los pacientes con TB presentan, aun en remisión sintomática, disfuncionalidad en un amplio espectro de ámbitos vitales. El aspecto cognitivo de la ToM se encontraría más afectado que la ToM emocional. No se observó una correlación significativa entre alteraciones en la funcionalidad y déficits en ToM(AU)

Introduction. Functional deficits are commonly observed in bipolar disorder after symptomatic remission. Social cognition deficits have also been reported, which could contribute to dysfunction in patients with bipolar disorder in remission. Materials and methods. Twelve bipolar disorder patients in symptomatic remission (7 patients with bipolar disorder type I and 5 with bipolar disorder type II) and 12 healthy controls completed the Reading the Mind in the Eyes Test and the Faux Pas Test to evaluate theory of mind (ToM). Both groups also completed the Functional Assessment Short Test (FAST). Results. The performance of the bipolar patients in the cognitive component of ToM was below normal, although the difference between the control group was not statistically significant (P=.078), with a trend to a worse performance associated with a higher number of depressive episodes (P=.082). There were no statistically significant differences between groups for the emotional component of ToM. Global functionality was significantly lower in bipolar patients compared to the control group (P=.001). Significant differences were also observed between both groups in five of the six dimensions of functionality assessed. No significant correlation was found between functionality and theory of mind. Conclusions. Bipolar patients in symptomatic remission exhibit impairments in several areas of functioning. Cognitive ToM appears more affected than emotional ToM. Deficits in ToM were not related to functional impairment(AU)

Theory of mind and functionality in bipolar patients with symptomatic remission.

INTRODUCTION: Functional deficits are commonly observed in bipolar disorder after symptomatic remission. Social cognition deficits have also been reported, which could contribute to dysfunction in patients with bipolar disorder in remission. MATERIAL AND METHODS: Twelve bipolar disorder patients in symptomatic remission (7 patients with bipolar disorder type I and 5 with bipolar disorder type II) and 12 healthy controls completed the Reading the Mind in the Eyes Test and the Faux Pas Test to evaluate theory of mind (ToM). Both groups also completed the Functional Assessment Short Test (FAST). RESULTS: The performance of the bipolar patients in the cognitive component of ToM was below normal, although the difference between the control group was not statistically significant (P=.078), with a trend to a worse performance associated with a higher number of depressive episodes (P=.082). There were no statistically significant differences between groups for the emotional component of ToM. Global functionality was significantly lower in bipolar patients compared to the control group (P=.001). Significant differences were also observed between both groups in five of the six dimensions of functionality assessed. No significant correlation was found between functionality and theory of mind. CONCLUSIONS: Bipolar patients in symptomatic remission exhibit impairments in several areas of functioning. Cognitive ToM appears more affected than emotional ToM. Deficits in ToM were not related to functional impairment.

Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders.

OBJECTIVE: To assess the sensitivity and specificity of two self-report instruments for detection of bipolarity in a sample of Argentinean patients. METHOD: Spanish versions of the MDQ and the BSDS were administered over four months at 11 sites in Argentina. Diagnoses were made using DSM-IV criteria and the MINI. The study sample consisted of patients diagnosed with Bipolar Disorder (BD) Types I, II, or NOS. BDNOS diagnoses were made using extended guidelines for bipolar spectrum symptoms. Unipolar patients were used as a control group. Of 493 patients screened, 354 completed evaluation by MDQ and MINI, and 363 by BSDS and MINI. RESULTS: Specificity of MDQ was 0.97 and BSDS was 0.81. MDQ sensitivity was 0.70 for bipolar type I (BD-I), 0.52 for bipolar II (BD-II) and 0.31 for bipolar not otherwise specified (BDNOS). BSDS sensitivities were 0.75, 0.70 and 0.51 respectively. LIMITATIONS: This study was performed in specialized outpatient settings and thus its results are not necessarily representative for other clinical settings. There was not a systematic evaluation of comorbid psychiatric disease or test-retest reliability. CONCLUSION: The local versions of the MDQ and the BSDS showed a sensitivity and specificity comparable to previous research. Our results indicate that in this sample, MDQ was more specific for BD and BSDS was more sensitive to detect BD-II and NOS. Since BD-I is more readily recognized than bipolar spectrum disorders, enhanced sensitivity of BSDS for soft bipolarity may be an advantage.

[Differential diagnosis between borderline personality disorder and bipolar disorder]. / Diagnóstico diferencial entre el trastorno límite de la personalidad y el trastorno bipolar.

The relationship between bipolar disorder and borderline personality disorder remains controversial since in both conditions there are overlapping and similar symptomatic dimensions. Symptomatic dimensions suitable to subserve differential diagnosis are: mood, mood variability mode, and personal and family history. Characteristics of psychotic symptoms may also be useful in the differentiation. On the other hand, anxiety symptoms, neuropsychological profiles, neuro-imaging procedures and biomarkers seem not to contribute to differentiate between both diseases. The presentation of nonsuicidal self mutilation behavior can offer some differences between bipolar and borderline personality disorders, but both can coexist in clinical comorbid forms and do not significantly contribute to the differential diagnosis. Differential diagnosis is complicated by the fact that a low percentage of patients can experience comorbidity of both conditions. In this work we review all these issues, and particularly emphasize the importance of sitematically take into account the patient background, the course that follows his or her disorder, together with the outcome in response to medical decisions.

[2nd Argentine consensus on the treatment of bipolar disorders 2010]. / II Consenso argentino sobre el tratamiento de los trastornos bipolares 2010.

The consensus guidelines of Argentine experts in the treatment of bipolar disorders are the result of three days of work of the 9 main local experts under the organization of the Argentine Association of Mood Disorders (ASATHU). This work is an update of the guidelines published on this journal in 2006. It was adopted a mixed criterion for its preparation: all the recent data of the evidence medicine based published until now were discussed and were balanced with the knowledge acquired from clinical experience of the local experts on the bipolar field. It presents general recommendations and suggested therapeutic sequences for maintenance, manic/hypomanic or mixed episode and depressive episode treatments. Bipolar disorders have been divided according to the international classifications in type I and II; with or without rapid cycling. This work also includes a series of recommendations for early and differential diagnosis of bipolar disorders.

[The impact on clinical practice of the concept of chronicity]. / El concepto de cronicidad y su impacto en la clínica.

Studies of higher level of evidence show that the clinic of chronic diseases such as schizophrenia or bipolar disorder is not crystallized and is liable to be changed positively by pharmacological and psychosocial interventions. Supporting the concept of chronicity or "clinical unchangeable", not being supported by scientific evidence, lies in the way of belief or prejudice. Thinking that chronic diseases can't be improved by therapeutic interventions may result in not offering treatment options. We could be facing a chronicity generated in the minds of colleagues and not in the scope of the clinical patients. The beliefs and prejudices of professionals in the mental health field might have a stigmatizing effect similar to that of the general population. Intense antistigma activity is needed not only in the general public but also within our field. The clarification of the concept of chronicity is located on this line.

El concepto de cronicidad y su impacto en la clínica / The impact on clinical practice of the concept of chronicity

Los estudios de mayor nivel de evidencia nos muestran que la clínica de enfermedades crónicas, como la esquizofrenia o el trastorno bipolar, no es cristalizada y es pasible de ser modificada, positivamente, por intervenciones farmacológicas y psicosociales. Sostener el concepto de cronicidad como clínica inmodificable, al no estar sustentado en la evidencia científica, se ubica en el campo de las creencias o los prejuicios. Pensar las patologías crónicas sin posibilidad de ser mejoradas por las intervenciones terapéuticas podría resultar en no ofrecer alternativas de tratamiento. Podríamos estar frente a una cronicidad que se genera en la mente de los colegas y no en las posibilidades de la clínica de los pacientes. Las creencias y prejuicios de los profesionales del campo de la Salud Mental tienen un efecto estigmatizador similar al de la población general. Es necesaria una intensa actividad anti-estigma no sólo en el público en general sino también dentro de los colegas de nuestro campo. El esclarecimiento sobre el concepto de cronicidad se ubica en esta línea.(AU)

Studies of higher level of evidence show that the clinic of chronic diseases such as schizophrenia or bipolar disorder is not crystallized and is liable to be changed positively by pharmacological and psychosocial interventions. Supporting the concept of chronicity or "clinical unchangeable", not being supported by scientific evidence, lies in the way of belief or prejudice. Thinking that chronic diseases can t be improved by therapeutic interventions may result in not offering treatment options. We could be facing a chronicity generated in the minds of colleagues and not in the scope of the clinical patients. The beliefs and prejudices of professionals in the mental health field might have a stigmatizing effect similar to that of the general population. Intense antistigma activity is needed not only in the general public but also within our field. The c1arification of the concept of chronicity is located on this line.(AU)

El concepto de cronicidad y su impacto en la clínica / The impact on clinical practice of the concept of chronicity

Los estudios de mayor nivel de evidencia nos muestran que la clínica de enfermedades crónicas, como la esquizofrenia o el trastorno bipolar, no es cristalizada y es pasible de ser modificada, positivamente, por intervenciones farmacológicas y psicosociales. Sostener el concepto de cronicidad como clínica inmodificable, al no estar sustentado en la evidencia científica, se ubica en el campo de las creencias o los prejuicios. Pensar las patologías crónicas sin posibilidad de ser mejoradas por las intervenciones terapéuticas podría resultar en no ofrecer alternativas de tratamiento. Podríamos estar frente a una cronicidad que se genera en la mente de los colegas y no en las posibilidades de la clínica de los pacientes. Las creencias y prejuicios de los profesionales del campo de la Salud Mental tienen un efecto estigmatizador similar al de la población general. Es necesaria una intensa actividad anti-estigma no sólo en el público en general sino también dentro de los colegas de nuestro campo. El esclarecimiento sobre el concepto de cronicidad se ubica en esta línea.

Studies of higher level of evidence show that the clinic of chronic diseases such as schizophrenia or bipolar disorder is not crystallized and is liable to be changed positively by pharmacological and psychosocial interventions. Supporting the concept of chronicity or "clinical unchangeable", not being supported by scientific evidence, lies in the way of belief or prejudice. Thinking that chronic diseases can t be improved by therapeutic interventions may result in not offering treatment options. We could be facing a chronicity generated in the minds of colleagues and not in the scope of the clinical patients. The beliefs and prejudices of professionals in the mental health field might have a stigmatizing effect similar to that of the general population. Intense antistigma activity is needed not only in the general public but also within our field. The c1arification of the concept of chronicity is located on this line.

[Revision of systematic treatment enhancement program for bipolar disorder (STEP-BD)]. / Revisión del Programa para la Mejoría Sistemática del Tratamiento del Trastorno Bipolar (STEP-BD).

The STEP-BD is a public initiative, created to generate data, obtained in pragmatic or real life research environments, from the bipolar disorder. The primary objectives are: to investigate the effectiveness of therapeutic interventions in bipolar disorder, the impact on the disease course of these interventions in the 'real life' and to raise the knowledge about the disease. This program included in six years, n = 4361 patients. This program is not a study in phases but an infrastructure for more than 40 published studies and 30 conference presentations. These studies aim to capture the heterogeneity of the disease in their different clinical presentations, treatments, comorbidities, functionality and quality of life. Patients entering the program have a common assessment. The program consists of two main pathways: the standard treatment and randomized treatment of acute bipolar depression, bipolar depression and refractory relapse prevention. In addition several studies completed the program in an attempt to give coherence to the different clinical presentations of this disease, different treatments and interventions for similar clinical phenomena.

Revisión del Programa para la Mejoría Sistemática del Tratamiento del Trastorno Bipolar (STEP-BD) / Revision of systematic treatment enhancement program for bipolar disorder (STEP-BD)

El programa STEP-BD es una iniciativa pública que surge de la necesidad de tener datos sobre el trastorno bipolar obtenidos en entornos de investigación pragmáticos o de la vida real. Los objetivos primarios son: investigar la efectividad de las intervenciones terapéuticas en el trastorno bipolar, el impacto en el curso de la enfermedad de estas intervenciones en entornos pragmáticos o de la vida real y aumentar el conocimiento sobre la enfermedad. Incluyó, en seis años, a 4361 pacientes. Este programa no es un estudio en fases, es una infraestructura compuesta por más de 40 estudios publicados y 30 presentaciones en congresos. Estos estudios tienen por objetivo captar la heterogeneidad de la enfermedad en sus presentaciones clínicas, tratamiento, comorbilidades, funcionalidad y calidad de vida. Los pacientes que ingresan al programa tuvieron una evaluación común. El programa consta de dos ramas principales: tratamiento estándar y tratamientos randomizados de depresión bipolar aguda, depresión bipolar refractaria y prevención de recaídas. Además, diversos estudios completan el programa en un intento de darle coherencia a las diferentes presentaciones clínicas de esta enfermedad, a los diferentes tratamientos y las diferentes intervenciones para fenómenos clínicos similares.(AU)

The STEP-BD is a public initiative, created to generate data, obtained in pragmatic or real life research environments, from the bipolar disorder. The primary objectives are: to investigate the effectiveness of therapeutic interventions in bipolar disorder, the impact on the disease course of these interventions in the "real life" and to raise the knowledge about the disease. This program included in six years, n = 4361 patients. This program is not a study in phases but an infrastructure for more than 40 published studies and 30 conference presentations. These studies aim to capture the heterogeneity of the disease in their different clinical presentations, treatments, comorbidities, functionality and quality of life. Patients entering the program have a common assessment. The program consists of two main pathways: the standard treatment and randomized treatment of acute bipolar depression, bipolar depression and refractory relapse prevention. In addition several studies completed the program in an attempt to give coherence to the different clinical presentations of this disease, different treatments and interventions for similar clinical phenomena.(AU)

Revisión del Programa para la Mejoría Sistemática del Tratamiento del Trastorno Bipolar (STEP-BD) / Revision of systematic treatment enhancement program for bipolar disorder (STEP-BD)

El programa STEP-BD es una iniciativa pública que surge de la necesidad de tener datos sobre el trastorno bipolar obtenidos en entornos de investigación pragmáticos o de la vida real. Los objetivos primarios son: investigar la efectividad de las intervenciones terapéuticas en el trastorno bipolar, el impacto en el curso de la enfermedad de estas intervenciones en entornos pragmáticos o de la vida real y aumentar el conocimiento sobre la enfermedad. Incluyó, en seis años, a 4361 pacientes. Este programa no es un estudio en fases, es una infraestructura compuesta por más de 40 estudios publicados y 30 presentaciones en congresos. Estos estudios tienen por objetivo captar la heterogeneidad de la enfermedad en sus presentaciones clínicas, tratamiento, comorbilidades, funcionalidad y calidad de vida. Los pacientes que ingresan al programa tuvieron una evaluación común. El programa consta de dos ramas principales: tratamiento estándar y tratamientos randomizados de depresión bipolar aguda, depresión bipolar refractaria y prevención de recaídas. Además, diversos estudios completan el programa en un intento de darle coherencia a las diferentes presentaciones clínicas de esta enfermedad, a los diferentes tratamientos y las diferentes intervenciones para fenómenos clínicos similares.

The STEP-BD is a public initiative, created to generate data, obtained in pragmatic or real life research environments, from the bipolar disorder. The primary objectives are: to investigate the effectiveness of therapeutic interventions in bipolar disorder, the impact on the disease course of these interventions in the "real life" and to raise the knowledge about the disease. This program included in six years, n = 4361 patients. This program is not a study in phases but an infrastructure for more than 40 published studies and 30 conference presentations. These studies aim to capture the heterogeneity of the disease in their different clinical presentations, treatments, comorbidities, functionality and quality of life. Patients entering the program have a common assessment. The program consists of two main pathways: the standard treatment and randomized treatment of acute bipolar depression, bipolar depression and refractory relapse prevention. In addition several studies completed the program in an attempt to give coherence to the different clinical presentations of this disease, different treatments and interventions for similar clinical phenomena.

Secuencia de un trance: alteraciones psicopatológicas secundarias a experiencias religiosas / Sequence of a trance: psychopathological disorders following religious experiences

Las alteraciones psicopatológicas secundarias a experiencias religiosas más frecuentes son los trastornos disociativos y los fenómenos de trance. Esta clínica no es frecuente observarla en los consultorios de práctica privada ni hospitalaria. Para realizar esta revisión se concurrió a sitios de culto donde los fenómenos de trance y posesión son frecuentes para observar su clínica y los métodos de inducción. Además se revisó la literatura publicada sobre el tema. Conclusiones: en la Ciudad de Buenos Aires los fenómenos de trance y los trastornos disociativos tienen una tasa de diagnóstico menor que en otros sitios. Los trances que evidenciamos fueron en su totalidad producto de inducciones.

The more frequent psychopathological alteration after religious experiences are the dissociative disorders and trance. It's not frequent to see this clinic in private practice or hospitals in Buenos Aires. To do this revision we went to religious sites where the trance and possession status are frequent, in order to observe their clinic and the methods to induce them. We made a bibliographic revision about trance. Conclusion: In Buenos Aires city the dissociative disorders and the trance are less diagnosed than in other sites. The trances that we saw were totally induced.

[Permanent psychiatric effects in former addicts to marijuana or stimulants]. / Efectos psiquiátricos permanentes en ex abusadores de marihuana o de estimulantes.

It's an evidence based data that the abuse of drugs produces toxic psychiatric effects, in the acute and sub acute phases of the intoxication and also in the recent abstinence. It is more conflicting the data about if they can produce or unmask vulnerabilities to long term psychiatric disorders; or to affect its course and phenomenology; or to influence the response to the therapeutic resources used to treat them, beyond the period of abstinence. The objective is to update the knowledge available on the ability of the marijuana and the stimulants to produce long term psychiatric disorders, or to unmask vulnerabilities to them. We have done an electronic bibliographical research in MEDLINE using the following key words: psychiatric disorders, amphetamine, stimulants, marijuana, cannabis, long term effects, psychosis, cognitive and cognitive deficits. The marijuana might induce permanent psychosis in subjects with vulnerability to schizophrenia or to psychosis. The cognitive effects are acute and subacute, related with the presence of delta-9-tetrahydrocannabinol in the central nervous system. The stimulants can produce a schizophrenia-like psychosis, and they can produce long term cognitive deficits. The stimulants also might produce subsyndromic mood disorders.