RESUMO

Despite the abundance of literature on treatment-resistant depression (TRD), there is no universally accepted definition of TRD, and available treatment pathways for the management of TRD vary across the Latin American region, highlighting the need for a uniform definition and treatment principles to optimize the management of TRD in Latin America. METHODS: Following a thematic literature review and pre-meeting survey, a Latin America expert panel comprising 14 psychiatrists with clinical experience in managing patients with TRD convened and utilized the RAND/UCLA appropriateness method to develop consensus-based recommendations on the appropriate definition of TRD and principles for its management. RESULTS: The expert panel agreed that 'treatment-resistant depression' (TRD) is defined as 'failure of two drug treatments of adequate doses, for 4-8 weeks duration with adequate adherence, during a major depressive episode'. A stepwise treatment approach should be employed for the management of TRD - treatment strategies can include maximizing dose, switching to a different class, and augmenting or combining treatments. Nonpharmacological treatments, such as electroconvulsive therapy, are also appropriate options for patients with TRD. CONCLUSION: These consensus recommendations on the operational definition of TRD and approved treatments for its management can be adapted to local contexts in the Latin American countries but should not replace clinical judgement. Individual circumstances and benefit-risk balance should be carefully considered while determining the most appropriate treatment option for patients with TRD.

RESUMO

BACKGROUND: The COVID-19 pandemic has tested the level of preparedness and readiness of governments globally. The demand for services exceeding the capacity of the health systems in both developed and developing countries has been the rule rather than the exception. Physicians and the rest of the health-care personnel have been put through unprecedented levels of demand, within a field of uncertainty, from an evolving and insufficient understanding of the pathophysiology of the viral process, the unclear benefit of face coverings used by the general public, numerous pharmacological candidates, insufficient personal protection equipment, and the highly expected vaccine. AIMS AND OBJECTIVES: Design a program to address the emotional and psychiatric needs of COVID-19 first response Healthcare personnel in Mexico. MATERIALS: in march 2020, the Mexican Psychiatric Association was invited to be part of the Workgroup for the fortification of Mental Health during Disasters of the Ministry of Health in Mexico. The charge was to develop a program to address the needs and prevent burn out in physicians and the rest of healthcare personal. The details of how this program was planned, implemented, and launched will be presented. RESULTS: The program was launched in two phases. Phase A through a chat with text messaging capability was launched on 25 April, 2020. B through telepsychiatric video calls, was launched on 15 June, 2020. Phase A had a very limited demand. Phase B also had a very limited demand until the month 5 September, 2020. CONCLUSIONS: from the time of program launch through the first four months, the demand was very low, what may be explained due to "normalization" of stress and/or stigma among healthcare professionals. Our personnel deserve the utmost support from their society.

RESUMO

As of June 2020 the number of Coronavirus cases in Canada, Mexico, Central America and the Caribbean are just under 2.5 million infections and over 140,000 deaths. The health systems in half of the countries in the Americas and the rest of the world have faced the pandemic positioned from different perspectives. While Canada and the United States already had extensive experience in the practice of telemedicine, other countries such as Mexico and the Caribbean, doctors from both private and public sectors have been forced to start practicing medicine remotely. As a result there have been limitations such as poor access to technology, lack of privacy legislation, and difficulties with fee collection among many others. These situations must be taken in account to understand what is happening in the region. On the other hand, the need to continue providing medical attention is indisputable. We understand that COVID 19 besides other systems damages the CNS, patients present severe neuropsychiatric symptoms that range from headache, anosmia, ageusia, confusional state alteration of consciousness, toxic metabolic encephalopathies, encephalitis, seizures, cerebral vascular events, Guillan Barre-type demyelinating neuropathies, to the extent of conditions such as anxiety, acute stress disorder, post-traumatic stress disorder, depression, and eventually psychotic episodes. As time passes we try to differentiate the origin of the symptoms. We will learn which of these symptoms are a result of metabolic complications, which others are due to drug's secondary effects and which ones are adaptive response. Therefor our contribution to the editorial supplements is given in two lines of analysis: disease physiopathology and ways to deliver treatment to the population.

Assuntos

RESUMO

Objective: The objective of this study is to examine the association of country of residence with body mass index (BMI) between Mexican and Colombian patients exposed to antipsychotics. We hypothesize that there will be a significant association between country of residence and BMI and that Mexican patients will have higher BMI than their Colombian counterparts.Design: The International Study of Latinos on Antipsychotics (ISLA) is a multisite, international, cross sectional study of adult Latino patients exposed to antipsychotics in two Latin American Countries (i.e. Mexico and Colombia). Data were collected from a total of 205 patients (149 from Mexico and 56 from Colombia). The sites in Mexico included outpatient clinics in Mexicali, Monterrey and Tijuana. In Colombia, data were collected from outpatient clinics in Bogotá. For this study we included patients attending outpatient psychiatric community clinics that received at least one antipsychotic (new and old generation) for the last 3 months. A linear regression model was used to determine the association of country of residence with BMI for participants exposed to an antipsychotic.Results: After controlling for demographics, behaviors, biological and comorbid psychiatric variables, there was a significant difference between Colombia vs. Mexico in the BMI of patients exposed to antipsychotics (ß = 4.9; p < 0.05).Conclusion: Our hypotheses were supported. These results suggest that differences in BMI in patients exposed to antipsychotics in Mexico and Colombia may reflect differences in prevalence of overweight/obesity at the population level in the respective countries, and highlights the involvement of other risk factors, which may include genetics.

Assuntos

RESUMO

BACKGROUND AND OBJECTIVES: Providing appropriate and culturally sensitive care to the rapidly growing number of U.S. Latinx older adults with psychiatric conditions presents a major public health challenge. We know little about older Latinx adults' perceived causes of mental health problems, offering clinicians limited insight to guide successful and culturally congruent treatment. Moreover, there is a paucity of mental health research examining heterogeneity in how Latinx individuals may attribute mental health symptoms. The present study sought to identify how Latinx and non-Latinx older adults attributed the sources of their mental health problems and how these types of attributions differ by ethnicity. RESEARCH DESIGN AND METHODS: This study analyzed data collected from a retrospective chart review and survey of 673 adults aged 55-95 years (430 Mexican origin and 244 non-Latinx) from a rural psychiatric outpatient clinic near the California-Mexico border. We conducted stratified latent class analysis (LCA) by race/ethnicity to explore the mental health attribution beliefs of Mexican-origin and non-Latinx clinic patients. RESULTS: Different LCA patterns for Mexican-origin Latinx versus non-Latinx groups were found. For non-Latinx adults, there was a class of individuals who attributed their mental health issues to social and financial problems. For Mexican-origin adults, there was a class of individuals who attributed their mental health issues to spiritual and/or supernatural factors, unaffected by acculturation level, depressive symptom severity, and time spent in the United States, but differing by gender. We found within-group heterogeneity: Not all Mexican-origin or non-Latinx older adults were alike in how they conceptualized their mental health. DISCUSSION AND IMPLICATIONS: Mexican-origin Latinx and non-Latinx older adults attributed their mental health issues to different causes. More Mexican-origin older adults attributed their symptoms to spiritual causes, even after controlling for contextual factors. Further research is needed to determine whether attribution beliefs are affected by specific mental health diagnoses and other cultural factors not measured in this study.

RESUMO

resumen está disponible en el texto completo

Abstract: Temperament and character are terms utilized to delinéate the participation of biologic and psychosocial factors in the development of normal and disordered personality. At times, biological factors, and in others rearing, education, psychological and social events at an early age are the main determinants. The American Psychiatric Association describes Borderline Personality Disorder (BPD) as characterized by a pattern of interpersonal, selfimage and affective instability, as well as notable impulsivity. In this disorder, temperament as an inherited factor plays an important role, as demonstrated by familial studies in which the disorder is more frequently present in the families of probands than non-probands. Other disorders where impulsivity is an outstanding feature, such as antisocial personality disorder and substance abuse, are also frequent in first degree relatives of patients with BPD. Psychological factors, such as sexual abuse during childhood, are particularly high in this disorder. This is believed to generate features such as emotional instability, distrust, and dissociative states. From this point of view, it is possible that BPD is a form of "adaptation" not only psychological and behavioral, but also biological. Changes in the volume of the amygdala and hippocampus have been described in the brain of women abused during childhood, and those with BPD. BPD is frequently present in clinical practice, either or not associated to other psychiatric disorders; it can be found anywhere from 11 to 40.4% according to the setting studied. This incidence is even higher in patients with multiple suicide attempts. The term "borderline" was established when this pathological condition was conceptualized to origínate between neurosis and psychosis. However, current understanding of personality is better explained with a psychobiological model based on various dimensions. There is one related to schizophrenia (cognitive-perceptual organization dimension) and others related to mood disorders (mood regulation dimension), impulse control (impulsivity-aggression dimension), and anxiety disorders (anxiety-inhibition dimension). Patients with BPD show persistent disturbance on the four dimensions. The combination of these disturbances, along with specific defense mechanisms and coping strategies, originate the characteristic behaviors of individuals with BPD. Regarding the first dimension (cognitive-perceptual organization), BPD patients manifest paranoid ideation and dissociative symptoms usually under severe stress. It is possible that frontal lobe functioning is compromised due to a reactive dopamine and norepinephrine surge in the prefrontal lobe. The disturbance in the second dimension (mood regulation) is manifested in BPD by rapid mood shifts due to excessive sensitivity to separation, frustration and criticism. Although present in all cluster B personality disorders, mood instability in BPD is responsible for stormy relationships, self-image and self-esteem fluctuations, constant rage and bad temper, physical fights, and feelings of emptiness. This mood instability seems to be related to a serotonin effect on the dopaminergic and noradrenergic systems. Disturbances in the third dimension (impulsivity-aggression) originate a lack of control in the use of alcohol and/or drugs, as well as binge eating, reckless driving, shopping sprees, suicide gesture/attempts, self mutilation, and uncontrollable/inappropriate anger. Most studies note the inverse relationship between serotonin levels, and impulsivity, aggression, and selfharm behavior. Finally, abnormalities in the fourth dimension (anxiety-inhibition) manifest as themselves frantic attempts to prevent real or imaginary abandonment. No neurobiological substrate has been proposed in this dimension. The growing evidence of neurobiological basis favors the utilization of pharmacological agents in the treatment of BPD. This paper reviews available publications on controlled clinical trials, hoping to provide a guide in the prescription of psychopharma-cological agents to the patient with BPD. These patients can benefit from pharmacological treatment for impulsivity, psychotic states, affective instability and depression. After establishing a diagnosis, and ruling out associated conditions -such as major psychiatric disorders, substance use disorders, and/or general medical conditions-, a treatment plan including medications can be implemented. Studies on selective serotonin reuptake inhibitors (SSRI's) show the efficacy of fluoxetine in diminishing irritability and aggression and, to a lesser degree, depressed mood. A study adding fluoxetine to behavioral dialectic therapy did not seem to improve the outcome. Fluvoxamine, an antidepressant from the same class, improved emotional lability. Antipsychotics have shown to be useful. Olanzapine is the most studied of the atypical antipsychotics. Case reports using quetiapine and clozapine have also been published. Haloperidol improved depression, anxiety and anger. Anticonvulsants such as carbamazepine, valprote and, more recently topiramate, were reported to improve depressed mood, aggression and self-mutilation. TCA's and MAOI's seemed to help in symptoms such as anxiety, anger, suicidal ideation and rejection sensitivity. In turn, benzo-diacepines were associated with decreased impulse control, in-creased aggression and risk for overdose. Based on this literature review, the following considerations can be made: Patients with BPD, where aggressive behavior, self-multilation, or chronic disphoria are the outstanding features, should be started on an antipsychotic and as second option an anticonvulsant. In resistant cases, clozapine or lithium should be considered. In patients where depressed mood, anxiety, or impulsivity predominate, it is recommended to start an SSRI; as a second option, and only in cases where the patient is reliable, consider a tricyclic antidepressant (TCA), and as a last option, a monoaminoxidaseinhibitor (MAOI). In the more unstable cases, a combination of two or more medications may be needed. Fortunately, there is one study evaluating the combination of fluoxetine and olanzapine. In the pratice, drug combinations are frequent, and they seem to be matter of craft rather than science, as the clinician commonly uses his/ her experience rather than the limited published evidence. Treatment with medication should be started at a low dose, slowly increased for at least four weeks, as most controlled studies available do not show improvement earlier. Therefore, it is not recommended to change or add medications before waiting for a reasonable period, in spite of a patient's demand expecting a faster relief to his/her suffering.