[Evaluation of antidepressant treatment in patient with comorbidity. Using informatics technology]. / Evaluación del tratamiento antidepresivo en pacientes con comorbilidad. El uso de la informática.

OBJECTIVE: To evaluate the quality of care and improvement opportunities of medically ill depressed patients in a Psychiatric Facility using electronic medical records. METHODS: Observational, retrospective study. A literature review was conducted to identify and analyze evidence based quality indicators. We scored the clinical records to estimate the proportion of continuous antidepressant treatment at 12 and 24 weeks, response and remission rates at 8 weeks, the use of clinimetric scales, evidence based psychotherapeutic interventions (cognitive and interpersonal), and the emergence of antidepressant related safety events. RESULTS: Of 100 patients with an average age of 48.7 years, 49 % and 34 % received treatment during 12 and 24 weeks respectively. 50 % had response and 28 % remission at 8 weeks. Use of clinimetric scales was registered in 33 % and psychotherapeutic interventions in 28 % of the interviews. One patient had seizures related to antidepressant use. CONCLUSIONS: An increase in the proportion of patients achieving remission and the use of clinimetric scales with psychotherapeutic interventions are improvement opportunities to look for in the care of depressed patients with medical comorbidity.

[Causes of non-cardiac chest pain: multidisciplinary perspective]. / Causas de dolor torácico no cardiaco.

BACKGROUND: Non-cardiac chest pain (NCCP) is defined by recurrent episodes of substernal chest pain non related to ischemic heart disease, it's origin being in many cases the gastrointestinal tract; however, it may be associated to psychosomatic disorder. OBJECTIVES: To investigate the main causes of NCCP and to evaluate associated psychiatric comorbidity. METHODS: Patients with NCCP referred by a cardiologist were assessed underwent an upper endoscopy, ambulatory pH monitoring and stationary esophageal manometry. NCCP was considered gastro esophageal reflux disease (GERD) positive when the endoscopy and/or ambulatory pH monitoring were abnormal. When all results were normal, the symptom was considered as a functional chest pain (FCP). Patients were assessed by the Psychiatry service and diagnosed in accordance to the Diagnostic and Statistics Manual of Mental Diseases, fourth edition (DSM-IV). Several other test were applied for the assessment of anxiety and depression. RESULTS: Thirty-four patients were included (25 women and nine men; average age: 46.2 +/- 11.56 years). Three patients were eliminated because of refusal of the psychiatric evaluation. In 21 (68%) patients, NCCP was GERD-positive and in 10 (32%) to FCP. The most common symptoms associated to chest pain were: heartburn in 23 (74%), regurgitation in 21 (68%) and dysphagia in 15 (48%) patients. Upper endoscopy was abnormal in four cases; ambulatory pH monitoring was abnormal in 21 (67.7%) patients. The frequency of psychiatric disorders related to NCCP was 52%, in 10 patients with GERD-positive (48%) and six patients with FCP (60%). Mayor depression was the most common diagnoses identified among both groups. CONCLUSION: The high frequency of GERD and psychiatric disorders found in NCCP supports the multidisciplinary approach to NCCP.

Trastorno depresivo mayor en México: la relación entre la intensidad de la depresión, los síntomas físicos dolorosos y la calidad de vida

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SUMMARY Background: Major Depressive Disorder (MDD) is a disease associated to emotional, vegetative and physical symptoms, including for the latter those pain-related symptoms. MDD has a high prevalence rate with a substantial burden of illness, and it expected that by 2020 it will become the second cause of world disability. The diagnosis of MDD is difficult due to the high prevalence of painful physical symptoms, and also due to the fact these symptoms are more evident that the embedded emotional ones. Over 76% of patients with MDD, report painful physical symptoms observed, like headache, abdominal pain, back pain and unspecific-located pain; observing these symptoms can even predict depression severity. In addition, the likelihood of psychiatric disease increases, importantly, with the number of physical symptoms observed; moreover, the remission of physical symptoms predicts the complete remission in MDD. We present an observational, prospective study to examine the clinical profile of Mexican outpatients suffering MDD and determine the relationship between depression severity, painful physical symptoms in quality of life and depression. Methods: Adult patients with current episodes of MDD, treated with antidepressants were included. MDD was defined according to the criteria of the Statistical Manual of Mental Disorders - 4th Edition (DSM-IV) or in the International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). Patients should have been free of depression symptoms prior to the current episode for at least 2 months. Duration of current episode should not exceed two years. Treatment-resistant patients and those with other psychiatric diagnosis were excluded. Treatment-resistance was defined as: a) a failure to respond to treatment when two different antidepressants were employed at therapeutic doses for at least four weeks each, b) when the subject was previously treated with IMAO inhibitors, c) when electro-convulsive therapy (ECT) was previously employed. Other exclusion criteria comprise previous or current diagnosis of schizophrenia, schizophreniform or schizoaffective disorder, bipolar disorder, dementia or mental impairment. Patients were selected in 34 centers in Mexico. Patients were classified according to the presence (SFD+) or absence (SFD-) of painful physical symptoms using the Somatic Symptom Inventory (SSI); SFD+ was defined as scores ≥ 2 for the pain-related items in the SSI (items 2, 3, 9, 14, 19, 27 and 28). Visual Analogue Scale (VAS) quantified pain severity (cervical pain, headache, back pain, shoulder pain, interference of pain in daily activities and vigil-time with pain). HAMD17 and CGI-S determined depression severity, while the Quality of Life in Depression Scale (QLDS) quantified subjective well-being. Linear regression models were employed to compare groups for VAS, HAMD17, CGI-S, and QLDS, to fit the confusions or clinical predictors when needed. Proportions between groups were established with Fisher exact test or logistic regression. Significance levels were established at 0.005 due to the observational nature of the study. In the result tables, standard deviation (SD) is reported as a variation around the mean value as Mean ± SD, and 95% confidence intervals are denoted 95% IC. Results: A total of 313 patients were enrolled in the study. All of the enrolled patients were Mexican, almost them were women and had at least a previous MDD episode. Painful physical symptoms were reported by 73.7% of patients, these patients were classified into the SFD+ group. Neither statistical nor clinical significant differences between the SFD+ and SFD- groups were found when analyzing socio-demographic variables (age, gender, ethnical origin) and disease history variables (number of previous episodes of MDD, in the last 24 months, duration of current episode). At baseline, patients had a CGI-S mean score of 4.6 and HAMD17 of 26.3. HAMD17 mean score (27.1) in SFD+ patients was significantly higher (p<0.0001) than the SFD- patients (23.8), but nonsignificant differences between groups were found for the subscales central, Maier & retard. CGI-S scores were similar between SFD+ and SFD-; 4.6 and 4.5 respectively (p>0.05). Prevalent painful physical symptoms were also the most painful, when a five-point scale was employed to measure severity, and comprised muscular pain (84.9%), cervical pain (84.2%) and headache (83.5%). SFD+ patients had higher pain severity in all VAS scales (p<0.0001), with perceived severity scores twice as large when compared to SFDgroup. In particular, the global pain VAS reported average values of 49.0 and 19.7 for the SFD+ and SFD- groups respectively. Patients came to the first psychiatric consultation treated with psychotherapy (27.9%), antidepressants (37.3%), anxiolytics (28.6%) and analgesics (9.7%); more than 50% of all patients were not taking any drugs or receiving psychotherapy for treatment of MDD at baseline. Analgesics were used only by 9.7% of patients for the treatment of painful physical symptoms in their current MDD episode. No significant differences between groups were found when comparing the use of psychotherapy, antidepressants, anxiolytics, antipsychotics, mood stabilizers or analgesics. Quality of life was poor for all patients, but significantly worse in the SFD+ group than in the SFD- group (QLDS scores of 23.2 and 20.0 respectively, p<0.001). Discussion: The diagnosis and symptoms manifestation can be influenced by local socio-cultural factors, in particular cultural differences are associated with the prevalence of painful physical symptoms, but this finding is not consistent. The results of this study can be extrapolated to the MDD Mexican population, as selection criteria comprised only operative diagnosis criteria, and not enrollment into the study took place due to the presence of painful physical symptoms. Patients included into the study presented a moderate to severe disease as measured with the HAMD17 scores. The high prevalence of painful physical symptoms in patients with depression was confirmed in this study; it has been reported the patients report pain-related symptoms as the main (even the only) symptom when consulting general practitioners. Painful physical symptoms in MDD include headache, cervical pain, back pain or neck pain; the presence of painful physical symptoms in depression is associated to higher intakes medication, but in this study more than 50% of subjects were not receiving any treatment, including psychotherapy. The treatment of MDD is by no means optimal, as only 30%- 40% of these patients reach complete remission of symptoms with their first antidepressant. Psychological symptoms respond to antidepressant treatment, but in general, this is not the case for the physical symptoms. The lack of efficacy can be explained as a failure in the treatment of these painful physical symptoms. Resolving these symptoms is even a predictor for the complete remission of MDD; the evidence might suggest that treatment of emotional and physical manifestations of depression could improve successful-treatment rates. Conclusion: As found in other reports, a high prevalence of painful physical symptoms was found in MDD patients. Increase in pain severity is associated with higher HAMD17 scores but not CGI-S scores; this discrepancy in the final rates obtained with both scales suggests that both emotional and physical dimensions of MDD should be considered when the clinical assessment is performed. We concluded that clinical judgment of Mexican psychiatrists differs between their global impression and a semi-structured interview in the same patient and therefore is fundamental that the clinical evaluation consists of both emotional and physical manifestations as important components of MDD.

A cost-effectiveness clinical decision analysis model for treatment of Schizophrenia.

BACKGROUND: Schizophrenia afflicts approximately 0.7% of Mexican citizens during their lifetime. This study explored whether the difference in clinical efficacy and safety between atypical antipsychotics and conventional neuroleptics results in decreases in use and cost of medical services in Mexico, offsetting the higher price of atypical antipsychotics. METHODS: A U.S. decision analytic Markov model was adapted for use in Mexico to determine cost-effectiveness of treatments and outcomes that Mexican patients with schizophrenia may experience over a 5-year period when treated with olanzapine, haloperidol, or risperidone. Model parameter estimates were based on clinical trial data, published medical literature, and where needed, clinician judgment. Direct medical costs were incorporated into the model and outcomes were estimated using lack of relapse and clinical outcomes based on the Brief Psychiatric Rating Scale (BPRS) as effectiveness indicators. All costs are reported in Mexican pesos. RESULTS: Over a 5-year period, the cost of treating schizophrenia ranged from 196,620 pesos per patient initiating therapy with haloperidol to 226,670 pesos per patient beginning therapy with risperidone. Olanzapine was estimated to have slightly better non-relapse and BPRS-based effectiveness outcomes, but comparative total medical costs compared to risperidone. Patients receiving olanzapine experienced 13 and 2% fewer relapses compared with patients on haloperidol and risperidone, respectively. The 5-year incremental cost-effectiveness ratio of olanzapine compared with haloperidol was 52,740 pesos per improved patient, BPRS-based outcome and 212,540 pesos per avoided relapse. Sensitivity analyses indicated the model was sensitive only to changes in drug costs. CONCLUSIONS: Compared with haloperidol, olanzapine therapy results in improved symptoms, fewer relapses, and is cost-effective, even with conservative values for key model parameters. Olanzapine results in slightly improved patient outcomes and comparable costs compared with risperidone.

Motivos de interconsulta psiquiátrica en pacientes con delirium / Psychiatric consultation motives in patients with delirium

Antecedentes: el delirium e un trastorno mental muy común y potencialmente fatal; por ello es necesario saber cómo detectarlo y, por ende, establecer procesos de diagnóstico más eficases y oportunos. Objetivo: evaluar las manifestaciones clínicas que generen la solicitud de interconsultas psiquiátricas a pacientes con diagnóstico definitivo de delirium. Material y métodos: se revisaron 1,474 referencias al Departamento de Psiquiatría del Hospital de Especialidades, del Centro Médico Nacional Siglo XXI, hechas entre 1995 y 1997. Todos los diagnósticos se realizaron de acuerdo con los criterios del DSM.IV. Resultados: doscientos dieciocho pacientes tuvieron delirium (14.7 por ciento); y las principales alteraciones de éstos fueron cognitivas (36.6 por ciento), de la conducta (21 por ciento y del afecto (20 por ciento). Conclusiones. es muy común que se confunda el delirium con la depresión. Entre los mismos servicios médicos y quirúrgicos hay diferencias en la apreciación de estas alteraciones, ya que los primeros descubren más trastornos del afecto, mientras que los segundos encuentran más cambios de la conciencia. Por otra parte, en cuanto al género de los pacientes, se identificaron más alteraciones efectivas en la mujer y cognitivas en el hombre

Enfermedades psiquiátricas en el insomnio / Insomnia in psychiatric diseases

Se considera que una de cada cinco personas desarrolla un trastorno mental en el curso de su vida, la manifestación sobresaliente de este problema puede ser el insomnio. Se presentan las características clínicas fundamentales de las principales patologías mentales (trastornos de ansiedad, trastornos de personalidad, esquizofrenia, trastornos somatoformes) y las alteraciones asociadas en el sueño. Se describen aproximaciones básicas de higiene del sueño y la utilidad de los psicofármacos en el insomnio