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Carta aos editores Measures of effect for cross-sectional studies

Medidas de associação nos estudos transversais Dear Editor, Measures of effect are used to compare the frequency of a disease and therefore can be used to study the associations between frequency of disease and risk factors.1 It is possible to compare any measure of frequency of disease (Odds, Risk, Rate, Prevalence) using the difference between them (absolute effect: Rate Difference, Risk Difference, Excess Risk) or the ratio between them (relative effect: Odds Ratio (OR), Risk Ratio, Rate Ratio, Prevalence Ratio). Reporting one or another measure of effect will mostly depend on the study design and the frequency of disease.2 For cross-sectional studies a commonly reported measure of effect is the Odds Ratio, rather than the Prevalence Ratio which is a suitable measure of effect for this kind of study design. It is common for ORs to be wrongly interpreted as Risk Ratios. For common mental disorders it can greatly overestimate the Prevalence Ratio and the use of OR will not necessarily lead to the same conclusions as from the Prevalence Ratio about effect modification or confounding.3-5 Prevalence Ratio is more difficult to estimate in a multivariate setting. Several alternatives have been discussed in the literature

for the analysis of binary outcomes in cross-sectional studies using the PR rather than OR. The simplest way is to transform the ORs obtained by logistic regression into PRs.3,4 Another possibility is to use a statistical model that directly estimates the PR and its confidence interval. Alternatives explored in the epidemiological literature are Cox regression with equal times of follow-up assigned to all individuals, log-binomial regression (a generalized linear model with a logarithmic link function and binomial distribution for the residue), Poisson regression with robust variance and complementary log-log model, where the link function is log (-log (1-π) and the distribution is binomial.3,5 Although the use of OR for cross sectional studies is not necessarily wrong, authors and referees should be aware of its correct interpretation and alternatives to it for cross sectional studies. Erico Castro-Costa Public Health and Aging Research Group, Oswaldo Cruz Foundation Rene Rachou Institute, Belo Horizonte (MG), Brazil Medical School, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil Health Service and Population Research, Institute of Psychiatry, King’s College London, London, UK Cleusa Pinheiro Ferri Health Service and Population Research, Institute of Psychiatry, King’s College London, London, UK

Disclosures Spekear’s honoraria

Ownership interest

Consultant/ Advisory board

Other3

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Astra-Zeneca JanssenCilag

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Writting group member

Employment

Research grant1

Erico de Castro e Costa

CPRR/Fiocruz FASEH

Other research grant or medical continuous education2

FAPEMIG

Cleusa Pinheiro Ferrei

King’s College London

Wellcome Trust

* Modest ** Significant *** Significant. Amounts given to the author's institution or to a colleague for research in which the author has participation, not directly to the author. Note: CPRR/Fiocruz = Centro de Pesquisas René Rachou da Fundação Oswaldo Cruz; FASEH = Faculdade da Saúde e Ecologia Humana; FAPEMIG = Fundação de Amparo à Pesquisa do Estado de Minas Gerais. For more information, see Instructions for authors.

References 1. Walter SD. Choice of effect measure for epidemiological data. J Clin Epidemiol. 2000;53(9):931-9. 2. Prince M, Stewart R, Ford T, Hotopf M, editors. Practical Psychiatry Epidemiology. Oxford: Oxford University Press; 2003. 3. Thompson ML, Myers JE, Kriebel D. Prevalence odds ratio or prevalence ratio in the analysis of cross sectional data: what is to be done? Occup Environ Med. 1998;55(4):272-7. 4. Barros AJ, Hirakata VN. Alternatives for logistic regression in cross-sectional studies: an empirical comparison of models that directly estimate the prevalence ratio. BMC Med Res Methodol. 2003;3:21. 5. Zocchetti C, Consonni D, Bertazzi PA. Estimation of prevalence rate ratios from cross-sectional data. Int J Epidemiol. 1995;24(5):1064-7.

Síndrome catatônica associada a transtorno bipolar misto: relato de caso e considerações terapêuticas Catatonic syndrome associated with mixed bipolar disorder: a case report and therapeutic considerations

Sr. Editor, A catatonia foi descrita pela primeira vez em 1874 por Kahlbaum, que a caracterizou como um distúrbio motor específico associado a diferentes transtornos psiquiátricos.1 Posteriormente, Kraepelin e Bleuler restringiram a catatonia a um subtipo específico da esquizofrenia. No entanto, após o questionamento de diversos autores, a associação entre catatonia e outros transtornos, notadamente os transtornos de humor, foi restabelecida.1 Rev Bras Psiquiatr. 2008;30(4):399-408

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Relatamos um caso de uma mulher com episódio misto, baseado nos critérios da CID-10 (F31-6),2 e sinais compatíveis com síndrome catatônica, segundo os critérios enumerados por Fink e Taylor ( dois ou mais sintomas catatônicos, em período de uma hora, em pelo menos duas ocasiões).1 Embora dados da literatura apontem que episódios catatônicos sejam relacionados à mania mista,3 esta é a primeira descrição da associação de síndrome catatônica ao episódio misto por autores brasileiros. Trata-se de paciente de 50 anos de idade. Foi admitida em serviço de urgência com quadro de agitação psicomotora, humor irritado, taquipsiquismo, anedonia e ideação delirante com conteúdo místico, erótico e autodepreciativo. Salientavamse estereotipias motoras, desidratação, verbigeração, palilalia e obediência automática. Não apresentava sinais parkinsonianos. Esse quadro se instalou progressivamente ao longo de 40 dias. Apresentava diagnóstico de quadro psiquiátrico há mais de 30 anos, com várias internações com sintomas de agitação e delírios, em uso crônico de antidepressivo – fluoxetina, 20 mg/dia, e haloperidol, 5 mg/dia. Na internação, frente à agitação da paciente, prescreveramse haloperidol, 10 mg/dia, biperideno, 2 mg/dia, e clonazepam, 2 mg/dia. Evoluiu ao longo da primeira semana com piora da agitação e insônia. Diante dos sinais sugestivos de síndrome catatônica, retirouse o neuroléptico, sendo prescritos o ácido valpróico, 1.250 mg/dia, e o lorazepam, 6 mg/dia. Os exames realizados foram: hemograma completo, eletrólitos, TGO, TGP, creatinina, VDRL, FTA-ABS, anti-HIV e tomografia computadorizada do encéfalo – sem alterações patológicas. Após quatro dias, apresentou melhora significativa do quadro catatônico, embora tenha permanecido com humor exaltado e com ideação persecutória. Permaneceu 26 dias internada, recebendo alta hospitalar assintomática em uso de ácido valpróico, 1.250 mg/dia, e clonazepam, 4 mg/dia.

A prática clínica nos mostra que a catatonia é uma síndrome que deve ser reconhecida e tratada adequadamente para se evitar conseqüências adversas para o paciente. O relato ilustra bem essa condição. O uso de neuroléptico de alta potência agravou o quadro de excitação motora e sua suspensão associada à introdução de lorazepam e valproato suscitaram em melhora rápida. A adesão ao tratamento, o diagnóstico adequado de transtorno bipolar e o uso de estabilizadores de humor são imprescindíveis na condução terapêutica de pacientes bipolares. O uso de antidepressivos deve ser evitado em episódios mistos. Embora mesmo o uso dos antipsicóticos atípicos seja controverso nos episódios de catatonia,1 há casos clínicos relatados na literatura em que o uso da olanzapina em transtorno bipolar resultou na remissão dos sintomas catatônicos associados.4,5 A literatura descreve a associação significativa entre quadro misto de humor e catatonia,3 bem como a resposta de quadros catatônicos a lorazepam e eletroconvulsoterapia.6 O uso de antipsicóticos de alta potência deve ser evitado devido ao risco de piora de catatonia maligna e possível progressão para síndrome neuroléptica maligna.1 Alexandre da Costa Val, Anderson Souza, Rodrigo Nicolato Instituto Raul Soares, Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte (MG), Brasil Antônio Lúcio Teixeira Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brasil João Vinícius Salgado Instituto Raul Soares, Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte (MG), Brasil Universidade FUMEC, Belo Horizonte (MG), Brasil

Financiamento e conflito de interesses Membro do grupo de autores

Local de trabalho

Verba de pesquisa1

Outro apoio à pesquisa ou educação médica continuada2

Honorários de palestrante

Participação acionária

Consultor/ Conselho consultivo

Outro3

Alexandre Costa Val

FHEMIG

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Anderson Souza

FHEMIG

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Rodrigo Nicolato

FHEMIG

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Antônio Lúcio Teixeira

UFMG

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João Vinícius Salgado

FHEMIG

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* Modesto ** Significativa *** Significativa. Montantes fornecidos à instituição do autor ou a colega para pesquisa onde o autor tem participação, não diretamente ao autor. Nota: FHEMIG = Fundação Hospitalar do Estado de Minas Gerais; UFMG = Universidade Federal de Minas Gerais.

Referências 1. Fink M, Taylor MA. Catatonia: a Clinician’s Guide to Diagnosis and Treatment. Cambridge, UK: Cambridge University Press; 2003. 2. Classificação de Transtornos Mentais e de Comportamento da CID-10 - Diretrizes Diagnósticas e de Tratamento para Transtornos Mentais em Cuidados Primários. Organização Mundial da Saúde. Porto Alegre: Artes Médicas; 1998. 3. Krüger S, Cooke RG, Spegg CC, Bräunig P. Relevance of the catatonic syndrome to the mixed manic episode. J Affect Disord. 2003;74(3):279-85. 4. Nicolato R, Romano-Silva MA, Correa H, dos Santos RR, Teixeira AL. Stuporous catatonia in an elderly bipolar patient: response to olanzapine. Aust N Z J Psychiatry. 2006;40(5):498. 5. Guzman CS, Myung VHMi, Wan YP. Treatment of periodic catatonia with olanzapine: a case report. Rev Bras Psiquiatr. 2007;29(4):380. 6. Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia, II: treatment with lorazepam and eletroconvulsive therapy. Acta Psychatr Scand. 1996;93(2):137-43.

Hypomanic episode secondary to sibutramine in a patient with type-I bipolar disorder

Episódio hipomaníaco secundário ao uso de sibutramina em paciente com transtorno bipolar do tipo I Dear Editor, A possible interaction between sibutramine and hypomanic state is reported in a previously normothymic patient with type-I bipolar disorder (DSM-IV diagnostic criteria). J.G.S. is a 27-year-old single white woman with a five-year history of bipolar type-I disorder. During the last 18 months she

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remained completely asymptomatic under carbamazepine (1000 mg/daily; blood level: 7.8 mg/L) and risperidone (2 mg/daily). In order to reduce her overweight (body-mass index = 32.40 kg/m2), sibutramine was introduced (10 mg/daily) and was increased to 15 mg/daily after a week. Two weeks later, she presented irritable reactions when her behavior and whereabouts were questioned, increased energy with frenzied activity and pressured speech. Mental status examination did not demonstrate inflated self-esteem, psychomotor excitement or flight of ideas [Young Mania Rating Scale (YMRS) = 15 points; 17-item Hamilton Rating Scale for Depression (HRSD) = 8]. Laboratory work-up, including complete blood count, renal, liver and thyroid function tests, was unremarkable. There was no previous history of substance abuse or another medical disorder. She has an uncle with history of type-I bipolar disorder. Her first manic episode occurred when she was 17 years old, without concomitant use of antidepressants. Since then, she has presented many hospitalizations due to manic and depressive episodes. These episodes occurred seven and three times, respectively, since the onset of the disorder. Mixed episodes never were observed. One of the manic episodes (YMRS = 51 points) occurred after one week under fluoxetine 60 mg/daily and carbamazepine 1000 mg/daily (blood level: 10.0 mg/L) during a depressive state (HRSD = 23). She also used lithium carbonate (600 mg/daily), but the patient complained about intense shivers and sedation under valproic acid (1000 mg/daily). With sibutramine withdrawal, increasing the dosage of carbamazepine to 1200 mg/daily (blood level: 9.0 mg/L) and introduction of clonazepam (1 mg/day), 12 days later, on discharge, her score on the YMRS had dropped to seven. Therefore, we hypothesized that sibutramine may be responsible for the hypomanic symptoms in our bipolar patient due to: 1) the temporal relation between the sibutramine introduction and the onset of hypomanic state; 2) and its remission after drug’s withdrawal.

References 1. Cordeiro Q, Vallada H. Sibutramine-induced mania episode in a bipolar patient. Int J Neuropsychopharmacol. 2002;5(3):283-4. 2. McElroy SL, Frye MA, Altshuler LL, Suppes T, Hellemann G, Black D, Mintz J, Kupka R, Nolen W, Leverich GS, Denicoff KD, Post RM, Keck PE Jr. A 24-week, randomized, controlled trial of adjunctive sibutramine versus topiramate in the treatment of weight gain in overweight or obese patients with bipolar disorders. Bipolar Disord. 2007;9(4):426-34. 3. Ferreira AD, Neves FS, da Rocha FF, Silva GS, Romano-Silva MA, Miranda DM, De Marco L, Correa H. The role of 5-HTTLPR polymorphism in antidepressant-associated mania in bipolar disorder. J Affect Disord. 2008. [Epub ahead of print]

Discussion Sibutramine is a b-phenylethylamine indicated for the management of obesity. It is recommended for obese patients with an initial bodymass-index ≥ 30 or ≥ 27 in the presence of other risk factors.1,2 Sibutramine is a satiety-inducing serotoninnoradrenaline reuptake inhibitor that acts predominantly via its primary and secondary metabolites.1,2 It provides a mean weight loss of approximately 5 kilograms during 1 year when compared with placebo.2 Although it can be hypothesized that sibutramine may act in a similar way to other serotonin reuptake inhibitors in inducing hypomania/mania in predisposed individuals, there is only one report in the literature associating a mania episode and this drug, in spite of another case report showing hypomania secondary to sibutramine-citalopram interaction.3-5 Despite the obvious severe limitations inherent to case reports in general, the present work suggests a possible relation between hypomanic symptoms and the use of sibutramine. Future clinical studies are needed to confirm this interaction, mainly in psychiatric patients who have shown obesity and glucose intolerance more frequently.5 Felipe Filardi da Rocha Mental Health Department, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil Thiago Ottoni Bamberg Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil Fernanda Curry Carneiro Pinto, Laura Mourão Guimarães e Gomes, Sandreane Silveira School of Medicine, Universidade José do Rosário Vellano, Belo Horizonte (MG), Brazil

4. 5.

Benazzi F. Organic hypomania secondary to sibutramine-citalopram interaction. J Clin Psychiatry. 2002;63(2):165. Rocha FF, Bezerra BP. The metabolic syndrome and psychiatric disorders: an association that cannot be forgotten. Arq Bras Endocrinol Metabol. 2006;50(6):1138-9.


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Quetiapine for the treatment of trichotillomania Quetiapina para o tratamento de tricotilomania

Dear Editor, Trichotillomania is a poorly understood disorder characterized by repetitive hair pulling that leads to noticeable hair loss, distress, and social or functional impairment. It is typically confined to one or two sites of the body. It most frequently affects the scalp but can also involve eyelashes, eyebrows, pubic hair, body hair, and facial hair.1,2 In this report, we describe a case of a patient treated with the atypical antipsychotic quetiapine. SRB is a 20-year-old woman, who was diagnosed with trichotillomania. She had a history of 8 years of hair plucking before seeking treatment. On admission, she presented anxiety and depressive symptoms, but did not meet criteria for either anxiety or mood disorders. Hair pulling worsened when she was anxious, but also occurred in other situations, especially if she was unfocused. Routine physical examinations and investigations were all within normal limits, including liver enzymes, except for a bald patch covering approximately 25% of her back scalp. Although cognitive behavioral therapy (CBT) consistently shows positive results for the treatment of trichotillomania and it is available in our unit, she refused the

References 1. Soriano JL, O’Sullivan RL, Baer L, Phillips KA, McNally RJ, Jenike MA. Trichotillomania and self-esteem: a survey of 62 female hair pullers. J Clin Psychiatry. 1996;57(2):77-82 2. Cohen LJ, Stein DJ, Simeon D, Spadaccini E, Rosen J, Aronowitz B, Hollander E. Clinical profile, comorbidity, and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry. 1995;56(7):319-26. 3. Stein DJ, Chamberlain SR, Fineberg N. An A-B-C model of habit disorders: hair-pulling, skin-picking, and other stereotypic conditions. CNS Spectr. 2006;11(11):824-7.

treatment, because it overlapped with work time. She was started on fluoxetine 20 mg per day, later titrated up to 40 mg per day. Hair pulling and anxiety symptoms improved, but activation side effects occurred, mainly insomnia and weight loss. After 4 weeks of fluoxetine 40 mg per day, quetiapine was introduced, beginning with 25 mg bedtime, titrated up to 100 mg in a week. Both fluoxetine activation side effects and hair pulling remitted in two weeks. Cessation of hair-plucking maintained, at the time of reporting, for a period of 4 months. To date, studies on trichotillomania treatment using behavioral and pharmacological interventions, alone or in combination are equivocal with few showing a sustained cessation of hair-plucking. These studies suggest that the combination of pharmacological treatment and habit reversal therapy (HRT), a cognitive behavioral technique, may be more efficacious for the treatment of trichotillomania than either approach alone.3 Our report supports the need of further investigation of quetiapine, other atypical antipsychotic drugs, and their association with selective serotonin reuptake inhibitors in the treatment of trichotillomania,4 particularly if therapeutic gains would maintain after medication discontinuation, or if additional structured psychosocial intervention is required to yield long-term remission.5 José Angelo Barletta Crescente Junior, Carlos Simón Guzman, Hermano Tavares Impulse Control Disorder Outpatient Unit, Institute and Department of Psychiatry, Universidade de São Paulo (USP), São Paulo (SP), Brazil

4.

5.

Bloch MH, Landeros-Weisenberger A, Dombrowski P, Kelmendi B, Wegner R, Nudel J, Pittenger C, Leckman JF, Coric V. Systematic review: pharmacological and behavioral treatment for trichotillomania. Biol Psychiatry. 2007;62(8):839-46. Trainor K. Treating Trichotillomania in children and adolescents: CBT versus medication. Am J Psychiatry. 2007;164(10):1610-11.


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Long-acting injectable risperidone improves quality of life in schizophrenic patients: a clinical case series

Melhora da qualidade de vida em pacientes esquizofrênicos tratados com risperidona de longa ação: uma série de casos Dear Editor, In the last decades, there has been an increased interest about the quality of life (QoL) in different psychiatric disorders,1 including schizophrenia.2 The presence of negative and depressive symptoms and the cognitive impairment is related with worse QoL in schizophrenic patients.3 Compared to conventional antipsychotics, atypical ones are effective against those symptoms. However, both conventional and atypical antipsychotics have poor compliance in oral regimens. In an outpatient clinic, 7 patients with DSM-IV schizophrenia disorder who were considered clinically stable and treated monthly with a long-acting typical agent for at least 6 months, were sequentially selected to be treated with long-acting injectable risperidone (LAIR) in a naturalistic, open-label study with a fixed dose of 25 mg every fourteen days per 12 weeks. LAIR was usually begun fourteen days after the last injection of haloperidol decanote (HD) and subsequently administered every fourteen days per 12 weeks. Patients were evaluated using the Brazilian versions of the Brief Psychiatric Rating Scale-Anchored (BPRS-A) for efficacy. Quality of life was assessed by the Brazilian version of the Heinrichs’ quality of life-rating scale (QLS). Those assessments were evaluated in face-to-face interviews via retrospective recall after every fourteen day-appointments. Interestingly, the statistical analysis was based on repeated measures analysis of variance (ANOVA-RM), which is a new approach to test the change of clinical data over time (at visit 1 to 7). Patients clinical characteristics are summarized: mean age was 41.4 years (SD = 10.8), 57.1% were illiterate, while the remaining had < 4 years. In terms of previous HD dosage distribution, 14% percent were treated with 150 mg/monthly, while 57% and 28% of participants were treated with 100 mg and 50 mg/monthly, respectively. Regarding the duration of previous HD treatment, 85% of participants were treated for more than 12 months and 15% more than 72 months. The mean BPRS-A total score was 42.0 (14.2) and 10.6 (4.9) (F = 11.49, p < 0.001), while the mean of QLS total score was 26.7 (11.1) and 52.8 (26.4) (F = 2.14, p = 0.039), in visit 1 and 7 respectively. Regarding the QLS, there was a statistically significant improvement in the total score and in three of the four subscales at the end of the study (Figure 1). This is the first reported investigation of LAIR in schizophrenia patients performed in Brazil. Previous studies have argued that generic QoL scales (such as SF-36) might not be suitable for clinical trials in severely ill schizophrenia patients for not being sensitive to subtle differences in treatment. Therefore specific scales should be used and QLS is the gold standard in schizophrenia.4 A significant improvement in the total score and in interpersonal relationships, intrapsychic foundations, and common objects and activities of QLS reproduced what was previously reported in clozapine-treated outpatients with chronic schizophrenia.5 Likewise, the lack of improvement in the instrumental role subscale could be accounted

for by either unemployment as suggested before5 or very little schooling of our patients. Further placebo-controlled studies could be carried out assessing quality of life by both generic and specific instruments simultaneously and establishing its correlation with depressive and cognitive symptoms. Acknowledgements E Castro-Costa is supported by the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG).

Erico Castro-Costa School of Human Health and Ecology (FASEH), Vespasiano (MG), Brazil René Rachou Research Center, Fundação Oswaldo Cruz (Fiocruz), Belo Horizonte (MG), Brazil King’s College London, Institute of Psychiatry, London, UK João Marcos de Castro Andrade Faculdade de Saúde e Ecologia Humana (FASEH), Vespasiano (MG), Brazil Lucas Quites Medical School, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte (MG), Brazil


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Disclosures Writting group member

Employment

Research grant1


Spekear’s honoraria

Ownership interest


Other3

Erico Castro-Costa

FASEH CPqRR/Fiocruz

FAPEMIG**

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Astra-Zeneca* Janssen-Cilag*

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João Marcos de Castro Andrade

FASEH

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Lucas Quites

UFMG

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* Modest ** Significant *** Significant. Amounts given to the author's institution or to a colleague for research in which the author has participation, not directly to the author. Note: FASEH = Faculdade de Saúde e Ecologia Humana; UFMG = Universidade Federal de Minas Gerais; FAPEMIG = Fundação de Amparo à Pesquisa do Estado de Minas Gerais; CPRR/Fiocruz = Centro de Pesquisas René Rachou da Fundação Oswaldo Cruz. For more information, see Instructions for authors.

References 1. Cucchiaro G, Dalgalarrondo P. Mental health and quality of life in pre- and early adolescents: a school-based study in two contrasting urban areas. Rev Bras Psiquiatr. 2007;29(3):213-21. 2. Souza LA, Coutinho ES. Associated factors to quality of life of patients with schizophrenia. Rev Bras Psiquiatr. 2006;28(1):50-8. 3. Ritsner MS. Predicting quality of life impairment in chronic schizophrenia from cognitive variables. Qual Life Res. 2007;16(6):929-37. 4. Cramer JA, Rosenheck R, Xu W, Thomas J, Henderson W, Charney DS. Quality of life in schizophrenia: a comparison of instruments. Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia. Schizophr Bull. 2000;26(3):659-66. 5. Mitsonis CI, Dimopoulos NP, Mitropoulos PA, Kararizou EG, Katsa AN, Tsakiris FE, Katsanou MN. Aripiprazole augmentation in the management of residual symptoms in clozapine-treated outpatients with chronic schizophrenia: an open-label pilot study. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(2):373-7.

Quality of life and childhood epilepsy

Qualidade de vida e epilepsia da infância Dear Editor, Among severe neurological conditions, epilepsy is the most prevalent, occurring in 0.5% of the general population, with a higher prevalence among children and adolescents. Several studies point that chronic diseases produce higher susceptibility to psychiatric morbidity when compared to control groups. The World Health Organization developed an instrument to assess the quality of life in the framework of a collaborative multicentre project (WHOQOL Group), which has been widely applied in Brazil in its Portuguese version.1 The Quality of life (QOL) approach has been considered one of the best alternatives for the psychic evaluation of children with chronic conditions. Unfortunately, we still cannot describe such development of instruments concerning the evaluation of the quality of life evaluation among children and adolescents. We present a study of QOL in children and adolescents with epilepsy (CAWE) using a self-applying questionnaire and comparing its performance to questionnaires applied to parents. We evaluated 28 outpatients with childhood epilepsy diagnosis and follow-up, aged 4 to 12 years and 11 months, and 28 matched healthy schoolchildren, and we also interviewed the parents of both groups. The Autoquestionnaire Qualité de Vie Enfant Imagé (AUQEI), validated for the local population,2 was applied to children and adolescents. We also applied the Children’s Global Assessment Scale (CGAS)3 and the Vineland Adaptive Behavior Scale (VINELAND),4 the

Table 1 - Groups’ characteristics and scales descriptives

n (%) (T test) Sex Male (5) Female (%) Age (years) < 8 (%) 8-12 (%) (to 1.83) CGAS Score: m (sd) (to 1.35) Total Vineland Score: m (sd) (to 6.28) Communication Vineland Score: m (sd) (to 5.15) Daily Activities Vineland Score: m (sd) (to 4.79) Social Skills Vineland Score: m (sd) (to 5.08) AUQEI Score: m (sd) (to 2.99)

Epileptic

Control

28 (100)

28 (100)

14 (50) 14 (50)

12 (42.86) 16 (57.14)

11 (39.29) 17 (60.71)

16 (57.14) 12 (42.86)

86.32 (17.35)

91.11 (6.21)

69.71 (17.76)

94.75 (10.64)

75.64 (18.89)

100.79 (16.97)

72.39 (24.31)

94.79 (8.92)

74.89 (13.80)

93.61 (13.28)

53.36 (5.72)

58.43 (6.69)

n: number of cases; CGAS: Children’s Global Assessment Scale; m: mean; sd: standard deviation; AUQEI: Autoquestionnaire Qualité de Vie Enfant Imagé T test: T independent test, < 0.05

last one composed by a total score and three subordinate domains: communication, daily living skills and socialization. CGAS and VINELAND were applied to parents. T independent test was used to analyze the data. The significance level adopted was of 5%. Results are presented in Table 1. No significant differences were observed between age groups (to 1.83) and as to CGAS scores (to 1.35). Significant differences were observed as to Vineland total scores. CAWE had worse performance than controls (to 6.28), as well as regarding to communication (to 5.15), daily living skills (to 4.79) and socialization (to 5.08) domains results. Significant differences were observed for AUQEI results (to 2.99). The CAWE group had worse results than matched controls. The majority of studies investigating the impact of epilepsy on QOL of children and adolescents have used proxy opinions, with clinician and/or parent reports. This study highlights the need for research investigating QOL from the direct perspective of children and considering issues in the context of a developmental perspective. For this purpose, in this study we used a self-reporting questionnaire. CAWE clearly demonstrated inferior performance in regard to self perception of QOL and to the development of an adaptive behavior, even though these went unrecognized by their parents, as shown by CGAS.


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In a previous study, chronically ill children with acute lymphocytic leukemia and juvenile rheumatoid arthritis, performed worse in adaptive behavior development.5 In this context, CAWE are no exception. With regardto global functioning, obtained from CGAS, there were no significant statistical differences in our study, demonstrating the absence of a higher incidence of complaints of this nature arising from parents, in relation to their chronic disease. Adequate instruments should be necessarily developed to assess perceptions of disease and treatment from chronic pediatric patients themselves, aiming to increase attention given to this growing and needing population in terms of mental health.5 Evelyn Kuczynski Grupo de Atendimento em Psiquiatria Infantil ao Epiléptico (GAPIE), Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo (SP), Brazil Projeto Distúrbios do Desenvolvimento, Departamento de Psicologia Clínica, Instituto de Psicologia, Universidade de São Paulo (USP), São Paulo (SP), Brazil

References 1. Fleck MPA e colaboradores. A avaliação de qualidade de vida: guia para profissionais da saúde. Porto Alegre: Artmed; 2008. 2. Assumpção Jr FB, Kuczynski E, Sprovieri MHS, Aranha EMG. Escala de avaliação de qualidade de vida (AUQEI – Autoquestionnaire qualité de vie enfant imagé): validade e confiabilidade de uma escala para qualidade de vida em crianças de 4 a 12 anos. Arq Neuropsiquiatr. 2000;58(1):119-27. 3. Shaffer D, Gould MS, Brasic J, Ambrosini P, Fisher P, Bird H, Aluwahlia S. A children’s global assessment scale (CGAS). Arch Gen Psychiatr. 1983;40(11):1228-31. 4. Sparrow SS, Balla DA, Cicchetti DV. Vineland adaptive behavior scales. Circle Pines (MN): American Guidance Service; 1984. 5. Kuczynski E, Silva CAA, Cristófani LM, Kiss MHB, Odone Filho V, Assumpção Jr FB. Evaluación de la calidad de vida en niños y adolescentes portadores de enfermedades crónicas y/o incapacitadoras: un estudio brasileño. An Pediatr. 2003;58(6):550-5.

Maria Sigride Thomé-Souza Grupo de Atendimento em Psiquiatria Infantil ao Epiléptico (GAPIE), Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo (SP), Brazil Laboratório de Neurofisiologia Clínica, Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo (SP), Brazil Lia A Fiore, Kette D R Valente Laboratório de Neurofisiologia Clínica, Instituto de Psiquiatria, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (USP), São Paulo (SP), Brazil Francisco B Assumpção Jr. Projeto Distúrbios do Desenvolvimento, Departamento de Psicologia Clínica, Instituto de Psicologia, Universidade de São Paulo (USP), São Paulo (SP), Brazil

Conseqüências psiquiátricas de cirurgia bariátrica em paciente esquizofrênica – relato de caso

Psychiatric consequences of bariatric surgery in a schizophrenic patient – case report Sr. Editor, A cirurgia bariátrica tem sido vista como uma grande esperança no tratamento da obesidade mórbida, doença que apresenta aspecto genético, é progressiva, multifatorial e constitui risco significativo para o desenvolvimento de várias comorbidades. Diversos estudos1,2 destacam a melhora na qualidade de vida e na saúde física e mental de pacientes que se submetem à cirurgia bariátrica. Segundo Kalarchian, desordens psiquiátricas são prevalentes entre candidatos a cirurgias psiquiátricas e estão associadas a uma obesidade mais grave e a um estado de saúde mais comprometido.3 Atualmente, diversos serviços e planos de saúde já exigem uma avaliação psicológica prévia à realização da cirurgia. Desordens psiquiátricas maiores, como a esquizofrenia, representam contraRev Bras Psiquiatr. 2008;30(4):399-408

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indicação relativa para este procedimento, embora poucos estudos tenham sido feitos sobre este tema. Segundo Lawlor4 e Hamoui,5 a esquizofrenia em remissão não é uma contra-indicação absoluta para a realização deste tipo de cirurgia. Entretanto, para um desfecho favorável, determinadas medidas são imprescindíveis, como acompanhamento psiquiátrico no pré- e pós-operatório para manejo das situações estressantes que possam daí advir e uso contínuo de medicação antipsicótica. Esquizofrenia com sintomas produtivos graves, não tratada, apresentando comorbidade com abuso de substâncias ou com compreensão deficitária das mudanças de hábitos impostas pela cirurgia constituem contraindicações absolutas para sua realização. Este relato de caso trata da história clínica de uma paciente esquizofrênica que realizou cirurgia bariátrica e seu desfecho após dois anos de evolução. Trata-se de paciente do sexo feminino, 32 anos, solteira, que trabalha como auxiliar administrativa em loja de material de construção. Iniciou tratamento psiquiátrico em março de 2002 em decorrência de surto psicótico diagnosticado como esquizofrenia paranóide. Recuperou-se parcialmente em três meses, após uso de haloperidol 10 mg. Entre os anos de 2002 a 2005, fez uso de diversos antipsicóticos, como haloperidol, tioridazina e risperidona, em dosagens apropriadas, sem remissão completa do quadro e com diversas recaídas. Entre as crises, apresentava alucinações auditivas, delírio, afeto superficial e isolamento social. Em agosto

de 2005, iniciou olanzapina 10 mg com boa resposta ao longo de seis meses de tratamento. Foi obesa desde a infância. Durante anos foi tratada sem sucesso com métodos mais conservadores para emagrecimento. Não apresentava comorbidades relacionadas à obesidade. Em abril de 2005, submeteu-se à cirurgia de derivação gástrica a Fobi-Capella. Teve excelente recuperação pós-operatória. Perdeu 40 kg no período de cinco meses (IMC reduziu de 40,5 para 25,1). Faz uso diário de polivitamínicos. Faz controle clínico pósoperatório a cada seis meses e já realizou as cirurgias plásticas reparadoras indicadas (abdômen e mamas). Sua vida mudou radicalmente depois da cirurgia. Sua autoestima melhorou sensivelmente. Mantém-se no emprego, conseguiu inserir-se melhor socialmente, inclusive mantendo relacionamento amoroso. As queixas sobre a obesidade deram lugar a questionamentos acerca de seu futuro, sua doença, as novas perspectivas de vida. Não houve, no período pós-operatório e durante o período de adaptação à sua nova realidade alimentar, retorno de sintomatologia psicótica mais importante. Atualmente em uso de olanzapina 20 mg.

Referências 1. Song AY, Rubin JP, Thomas V, Dudas JR, Marra KG, Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006;14(9): 1626-36. 2. Buddeberg-Fischer B, Klaghofer R, Krug L, Buddeberg C, Müller MK, Schoeb O, Weber M. Physical and psychosocial outcome in morbidly obese patients with and without bariatric surgery: a 4 1/2-year followup. Obes Surg. 2006;16(3):321-30.

3.

Electroconvulsive therapy and monoamine oxidase inhibitors

evidence that anesthesia is safe when performed in patients taking MAOI.2,3 The most common adverse reactions are hyperpyrexia, hypertension, and muscle twitching. Another shortcoming would be that the long-term use of MAOI may downregulate post-synaptic central and peripheral receptors activity (β, α1 and α2 adrenergic; 5HT1 and 5HT2), causing hypotension in the withdrawal process. The suggestion would be to keep the use of the drug (MAOI).3 Dolenc et al. found 100 case reports of anesthesia and MAOI use in the literature, with few complications. When the basic recommendations for MAOI use were followed, the outcomes were positive. The authors themselves reported 4 cases, with no complications and good outcomes over depressive symptoms. The hemodynamic patterns did not differ from those registered in the first cycle of ECT.4 We would like to describe a case of refractory depression treatment using ECT in a patient taking high doses of tranylcypromine:

Eletroconvulsoterapia e inibidores da monoaminoxidase

Dear Editor, Up to 30% of the depression cases can be named as refractory.1 These cases are resistant even to electroconvulsive therapy (ECT). One possibility to overcome refractoriness is to potentiate ECT with a monoamine oxidase inhibitor (MAOI). Monaco et al. reported one of the first case series of patients (n = 26) taking low doses of tranylcypromine and undergoing ECT, with no additional adverse reactions. From the anesthesiological point of view, there is

Maria Cristina Bechelany Hospital de Ensino Instituto Raul Soares, Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte (MG), Brasil

4. 5.

Kalarchian MA, Marcus MD, Levine MD, Courcoulas AP, Pilkonis PA, Ringham RM, Soulakova JN, Weissfeld LA, Rofey DL. Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry. 2007;164(2):328-34. Lawlor BA, Rand CS. Schizophrenia and gastric surgery for obesity. Am J Psychiatry. 1986;143(10):1321. Hamoui N, Kingsbury S, Anthone GJ, Crookes PF. Surgical treatment of morbid obesity in schizophrenic patients. Obes Surg. 2004;14(3):349-52.


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E.D.S.O., female, 37 years, was referred to our ECT service. Because of suicidal thoughts, we moved her to our infirmary. No mood disorders had been detected before she started to become ill, about eight years ago. In 1999, she started to treat depression with fluoxetine, with a good response. She worsened in 2001, when her sister committed suicide. Since then she never had any other period of euthimia, with 3 suicide attempts and intermittent psychotic features in the period. She had already used nortriptyline; paroxetine; mirtazapine; tranylcypromine; fluoxetine and nortriptyline; all in therapeutic doses. She came using fluoxetine 80 mg/d. The results of this first series (20 sessions, bilateral) were mild, but her suicidal ideation remitted. We interrupted ECT and fluoxetine and started tranylcypromine up to 80 mg/d, again with weak results. Then we decided to associate tranylcypromine and ECT. Her initial score on Beck Depression Inventory (BDI) was 23. She underwent right Unilateral ECT, twice a week, charge of 200 mC, adequate

duration. There were no complications and no major hemodynamic changes. This second trial had a better response. She rated her improvement in 40%. After 18 ECT sessions, her BDI score was 14, an improvement of 40% (from 23 to 14). Our case shows that even high doses of tranylcypromine can be used safely and this association can be useful for many refractory patients who suffer of severe depression. High doses of MAOI, particularly tranylcypromine, do not contraindicate ECT per se. More studies are needed to find effective means to potentiate the effects of ECT. Rafael Bernardon Ribeiro, Moacyr Alexandro Rosa, Sérgio Paulo Rigonatti Institute of Psychiatry, Clinical Hospital, Medical School, Universidade de São (USP), São Paulo (SP), Brazil

Disclosures Writting group member

Employment

Research grant1


Spekear’s honoraria

Ownership interest


Other3

Rafael Bernardon Ribeiro

USP

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Lundbeck* Cristália* Sandoz* Mantecorp*

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Moacyr Alexandro Rosa

USP

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Sérgio Paulo Rigonatti

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Cristália* Sandoz*

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* Modest ** Significant *** Significant. Amounts given to the author's institution or to a colleague for research in which the author has participation, not directly to the author. Note: USP = Universidade de São Paulo. For more information, see instructions to authors.

References 1. Berlim MT, Turecki G. Definition, assessment, and staging of treatmentresistant refractory major depression: a review of current concepts and methods. Can J Psychiatry. 2007;52(1):46-54. 2. Sprung J, Distel D, Grass J, Bloomfield EL, Lavery IC. Cardiovascular collapse during anesthesia in a patient with preoperatively discontinued chronic I-MAO therapy. J Clin Anesth. 1996;8(8):662-5. 3. O’Hara JF Jr, Maurer WG, Smith MP. Sufentanil-Isoflurane-nitrus oxide anesthesia for a patient monoamine oxidase inhibitor and tricyclic antidepressant. J Clin Anesthesia. 1995;7(2):148-58. 4. Dolenc TJ, Habl SS, Barnes RD, Rasmussen KG. Electroconvulsive therapy in patients taking monoamine oxidase Inhibitors. J ECT. 2004;20(4):258-61.

Síndrome de Gilles de La Tourette em criança portadora do transtorno do humor bipolar Gilles de la Tourette syndrome in a child with bipolar disorder

Sr. Editor, O transtorno do humor bipolar (THB) em crianças apresenta características clínicas bastante peculiares como predominância de estados mistos e ciclagem ultrarápida.1 A comorbidade de THB

com síndrome de Gilles de La Tourette (SGT) na infância tem chamado atenção, mas os fatores associados ainda são pouco conhecidos.2-5 Relatamos o caso de um menino com THB encaminhado ao Ambulatório de Transtornos Afetivos do Serviço de Psiquiatria da Infância e Adolescência (ATA-SEPIA) do Instituto de Psiquiatria do Hospital das Clínicas (IPq-HC) da Faculdade de Medicina da Universidade de São Paulo (FMUSP), cujos sintomas de SGT somente ficaram evidentes após a retirada da medicação que atuava como estabilizadora de humor. Relato de caso LPM, 10 anos e do sexo masculino. Aos seis anos, teve início quadro de agressividade, agitação e hiperatividade. Havia sido tratado com carbamazepina sem melhora e, subseqüentemente com olanzapina, que aumentou a ansiedade. Posteriormente, medicado com metilfenidato, houve piora dos sintomas disruptivos, sendo desencadeado o primeiro episódio de mania. Aos 10 anos apresentava sintomas de euforia, agitação psicomotora, grandiosidade e irritabilidade. Recebeu na ocasião doses diárias de risperidona (12 mg) e divalproato de sódio (DVP) (500 mg) sem melhora significativa. Encaminhado ao ATA-SEPIA, foi internado para observação e controle medicamentoso. Recebeu alta após 35 dias, com estabilização parcial do humor utilizando risperidona 8 mg/dia e DVP 1.000 mg/dia. No seguimento ambulatorial, foi associado o carbonato de lítio (CL) 1.050 mg/dia com melhora significativa das oscilações de humor e explosões de raiva. Cinco meses após, Rev Bras Psiquiatr. 2008;30(4):399-408

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voltou a apresentar oscilações diárias de humor. Na ocasião, a dosagem sérica dos estabilizadores de humor mostrava níveis eficientes (DVP = 122 ug/ml e litemia = 0,7 mEq/l), mas os medicamentos haviam proporcionado alterações de prolactina (28,9 ng/ml) e TSH (8,78 uU/ml). O paciente foi novamente internado. Na segunda internação, CL e risperidona foram rapidamente descontinuados e o DVP reduzido lentamente. Ainda em uso de DVP 250 mg/dia, no décimo dia de internação, o paciente apresentou melhora significativa e recebeu alta para prosseguir o tratamento ambulatorial. Quinze dias após a retirada completa de risperidona, ainda eutímico, o paciente começou a apresentar diversos tiques motores e fônicos. A intensidade dos tiques lhe conferia um aspecto de inquietação psicomotora, impossibilitando-o de executar qualquer atividade. Ele nunca havia apresentado sintomas semelhantes antes. Optou-se pela re-introdução da risperidona 3 mg/dia, visto que a retirada abrupta do antipsicótico exacerba sintomas de tiques em SGT, associando o DVP 500 mg/dia. Os tiques motores e fônicos remitiram completamente após 30 dias e o humor manteve-se estável.

prejuízos no funcionamento e desenvolvimento. Apresentam em comum sintomas como explosões de raiva, humor irritado e impulsividade.1,2,5 Pesquisas têm mostrado que indivíduos com SGT e THB apresentam mais comorbidades psiquiátricas e conseqüentemente maiores prejuízos de funcionamento.3,4 Essas co-ocorrências de sintomas podem levar à confusão diagnóstica, mesmo em se tratando de condições psicopatológicas distintas, com quadros clínicos e evoluções particulares. O presente caso mostra que as alterações do humor produzidas pelo THB foram mais significativas desde o início e sobrepuseramse aos sintomas de SGT, de forma que o segundo diagnóstico nunca havia sido considerado. Entretanto, a presença latente de SGT poderia explicar as dificuldades de controle inicial,3 quando nem as altas doses de antipsicóticos conseguiam controlar os comportamentos disruptivos do paciente, sendo necessário interná-lo. É importante que se faça o diagnóstico diferencial com o intuito de se evitar erros e conduções equivocadas no tratamento clínico e psicoterápico.3-5 Miguel Angelo Boarati, Ana Regina G Lage Castillo, José Carlos Ramos Castillo, Lee Fu-I Instituto de Psiquiatria, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo (SP), Brasil

Discussão Os relatos sobre a comorbidade de THB com SGT em crianças são raros. Ambas são patologias que podem causar graves Financiamento e conflito de interesses

Honorários de palestrante

Participação acionária

Consultor/ Conselho consultivo

Outro3

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Outro apoio à pesquisa ou educação médica continuada2 ---

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Membro do grupo de autores

Local de trabalho

Verba de pesquisa1

Miguel Angelo Boarati

Ipq-HCFMUSP Ipq-HCFMUSP Ipq-HCFMUSP Ipq-HCFMUSP

Ana Regina G. Lage Castillo José Carlos Ramos Castillo Lee Fu-I

* Modesto ** Significativa *** Significativa. Montantes fornecidos à instituição do autor ou a colega para pesquisa onde o autor tem participação, não diretamente ao autor. Nota: Ipq-HC-FMUSP = Instituto de Psiquiatria do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Mais informações, veja Instruções aos autores.

Referências 1. Findling RL, Gracious BL, McNamara NK, Youngstrom EA, Demeter CA, Branicky LA, Calabrese JR. Rapid, continuous cycling and psychiatric co-morbidity in pediatric bipolar I disorder. Bipolar Disord. 2001;3(4):202-10. 2. Bleich A, Bernout E, Apter A, Tyano S. Gilles de la Tourette syndrome and mania in a adolescent. Br J Psychiatry. 1985;146:664-5. 3. Robertson MM. Mood disorders and Gilles de la Tourette’s syndrome: An update on prevalence, etiology, comorbidity,

4. 5.

clinical associations, and implications. J Psychosom Res. 2006;61(3):349-58. Burd L, Kerbeshian J. Gilles de la Tourette’s syndrome and bipolar disorder. Arch Neurol. 1984;41(12):1236. Berthier ML, Kulisevsky J, Campos VM. Bipolar disorder in adult patients with Tourette’s syndrome: a clinical study. Biol Psychiatry. 1998;43(5):364-70.


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