EVENTOS ROSAVIENTOS

VII CONGRESO INTERNACIONAL DE PREVENCIÓN

Y ASISTENCIA DE LA DROGADEPENCENCIA
CORDOBA. ARGENTINA

8, 9 y 10 de Octubre de 2009

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En el marco del Congreso Internacional Organizado por el Programa Cambio, el día viernes 9 de octubre a las 11.00 Hs el Dr Ricardo García, junto a colegas de HAMSA NEUROCIENCIAS, Dr Exequiel Baravalle y la Dra Marina Bergoglio, expondrán sobre Benzodiazepinas, conceptos generales, dependencia y uso racional.

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Por su parte la Lic Claudia Sosa, en representación del PROGRAMA DEL SOL, junto a la Lic María Teresa Fernadez Alvarez, expondran sobre "Una experiencia de prevención inespecífica del consumo de drogas en el nivel medio. Reformulación del acuerdo de convivencia" el día sabado 10 de Octubre a las 11.30 Hs.

ISBD. Reporte de Expertos

The International Society for Bipolar Disorders (ISBD) Task Force report on the nomenclature of course and outcome in bipolar disorders

Tohen, M.; Frank, E.; Bowden, C.L.; Colom, F.; Ghaemi, S.N.; Yatham, L.N.; Malhi, G.S.; Calabrese, J.R.; Nolen, W.A.; Vieta, E.; Kapczinski, F.; Goodwin, G.M.; Suppes, T.; Sachs, G.S.; Chengappa, K.N.R.; Grunze, H.; Mitchell, P.B.; Kanba, S.; Berk, M.

Bipolar Disorders Vol: 11 Nro: 5 Págs: 453 - 473 Fecha: 01/08/2009

Resumen

Objectives: Via an international panel of experts, this paper attempts to document, review, interpret, and propose operational definitions used to describe the course of bipolar disorders for worldwide use, and to disseminate consensus opinion, supported by the existing literature, in order to better predict course and treatment outcomes.

Methods: Under the auspices of the International Society for Bipolar Disorders, a task force was convened to examine, report, discuss, and integrate findings from the scientific literature related to observational and clinical trial studies in order to reach consensus and propose terminology describing course and outcome in bipolar disorders.

Results: Consensus opinion was reached regarding the definition of nine terms (response, remission, recovery, relapse, recurrence, subsyndromal states, predominant polarity, switch, and functional outcome) commonly used to describe course and outcomes in bipolar disorders. Further studies are needed to validate the proposed definitions.

Conclusion: Determination and dissemination of a consensus nomenclature serve as the first step toward producing a validated and standardized system to define course and outcome in bipolar disorders in order to identify predictors of outcome and effects of treatment. The task force acknowledges that there is limited validity to the proposed terms, as for the most part they represent a consensus opinion. These definitions need to be validated in existing databases and in future studies, and the primary goals of the task force are to stimulate research on the validity of proposed concepts and further standardize the technical nomenclature.


Bipolar Disord 2009: 11: 453–473. (C)2009 The Authors.
Journal compilation (C) 2009 John Wiley & Sons A ⁄ S.

Nuevos Enfoques Acerca del Uso de los Antidepresivos

¿Por qué los antidepresivos no son antidepresivos?
STEP-BD, STAR*D y el retorno de la depresión neurótica

Nassir Ghaemi, S.

Bipolar Disorder 2008, 10 de diciembre, 8: 957-968


La opinión clínica ampliamente difundida de los “antidepresivos” como altamente efectivos y específicos para el tratamiento de todos los tipos de trastornos depresivos es exagerada. Esta conclusión aleccionadora se basa en los recientes hallazgos de los proyectos STEP-BD y STAR*D patrocinados por NIMH. Los antidepresivos tienen una eficacia a corto plazo limitada en trastornos depresivos unipolares y menor en la depresión bipolar aguda. Su efectividad preventiva a largo plazo es incierta en la depresión mayor recurrente y dudosa en la depresión bipolar recurrente. Estas limitaciones, pueden, en parte, reflejar el concepto excesivamente amplio de depresión mayor, así como generar expectativas poco realistas sobre la eficacia general de fármacos considerados “antidepresivos”.

La depresión refractaria al tratamiento puede revelar el fracaso para distinguir las enfermedades depresivas, en particular, el trastorno bipolar que es intrínsecamente menos sensible a los antidepresivos. Probablemente los antidepresivos deberían ser evitados en la depresión bipolar, estados mixtos depresivo-maníacos y en la depresión neurótica.

Las expectativas de antidepresivos para tipos específicos de pacientes con síntomas de depresión o ansiedad requieren una reevaluación crítica. El resurgimiento del concepto de depresión neurótica posibilitaría la identificación de pacientes con distimia y ansiedad de leve a moderada, crónica o episódica que es improbable que se beneficien mucho con los antidepresivos. Los criterios diagnósticos para la reactivación del concepto de depresión neurótica están propuestos.

Trastorno Bipolar. Hipomania Disfórica

HACIA LA DELINEACION CLINICA DE LA HIPOMANIA DISFORICA.
DILEMAS OPERACIONALES Y CONCEPTUALES.

Original Article

Toward a clinical delineation of dysphoric hypomania – operational and conceptual dilemmas

Akiskal HS, Benazzi F.

Bipolar Disord 2005: 7: 456–464. ©
Blackwell Munksgaard, 2005

Objective: Unlike dysphoric mania, we are unaware of any formal studies of dysphoric hypomania (DH). For this reason, DH is not formally recognized by DSM-IV and ICD-10. Analogous to the DSM-IV approach in the diagnosis of manic mixed state, in this exploratory study we operationalized DH as coexisting full syndromal hypomanic and major depressive states.

Methods: In an Italian outpatient private practice setting, 320 BP-II outpatients [meeting DSM-IV criteria except for shorter (>2 days) floor duration for history of hypomanic episodes] were further interviewed with the modified SCID-CV for the simultaneous presence of hypomanic and depressive signs and symptoms during the index presenting affective episode or its exacerbation. Hypomania always included irritable mood plus at least four hypomanic signs and symptoms. Such non-euphoric hypomania had to last at least 1 week.

Results: Only 45 (14.0%) met our proposed criteria for DH. Less stringently defined depressive mixed states (DMX) were excluded from further analyses. When compared with 120 of the 320 (37.5%) “pure” BP-II (i.e., not meeting mixed state criteria), DH emerged as an irritable affective state, demonstrated a significantly higher rate of females, mood lability, racing/crowded thoughts, distractibility, increased talkativeness, psychomotor agitation, and increased goal-directed drives. Psychomotor agitation/activation had a specificity of 87% and sensitivity of 94%, correctly classifying 92% of cases of DH.

Conclusions: The DSM-IV concept of dysphoric manic mixed state can be extended to DH. In the latter, eutrophic exuberance is replaced by irritable-labile mood, and the hypomanic expansiveness finds expression in mental, psychomotor and behavioral activation that could involve increased drives (e.g., travel, substances, and sex) and social disinhibition. It is useful to contrast the foregoing picture of DH as
hypomanic exuberance muted by leaden paralysis, with that of our previous work on DMX as a major depressive mixed state with more subtle excitatory hypomanic intrusions. We discuss methodologic, theoretical and practical implications of categorical (DH) and dimensional (DMX) conceptualizations of mixed states beyond mania.

Hagop S Akiskal a,b and Franco Benazzi c

a International Mood Center, University of California
at San Diego, La Jolla,
b VA Medical Center, San Diego, CA, USA,
c Outpatient Psychiatry Private Center (Ewald Hecker Center), Ravenna, Italy

Key words: bipolar II disorder – dysphoric
hypomania – major depression – mixed state

Received 16 June 2004, revised and accepted for publication 19 June 2005

Corresponding author: Hagop S Akiskal, MD,
International Mood Center, University of California
at San Diego, 3350 La Jolla Village Dr (116-A), San
Diego, CA 92161, USA. Fax: 858 534 8598;
e-mail: hakiskal@ucsd.edu

Trastorno Bipolar y Tabaco

Original Article

Tobacco smoking behaviors in bipolar disorder: a comparison of the general population, schizophrenia, and major depression

Diaz FJ, James D, Botts S, Maw L, Susce MT, de Leon J.


Objectives: This study compared the prevalence of tobacco smoking behaviors in patients with bipolar disorder with normal and psychiatric (schizophrenia and major depression) controls. The main goal was to establish that bipolar patients smoke more than normal controls. Differences with psychiatric controls were explored.

Methods: Samples of 424 patients (99 bipolar, 258 schizophrenia and 67 major depression) and 402 volunteer controls were collected in Central Kentucky. Smoking data for Kentucky_s general population were available. Odds ratios (ORs) and their 95% confidence intervals (CIs) were used to establish the strength of associations. Logistic regression was used to adjust ORs for confounding variables.

Results: Using epidemiological definitions of smoking behaviors and the general population as controls provided bipolar disorder unadjusted ORs of 5.0 (95% CI: 3.3–7.8) for current cigarette smoking, 2.6 (95% CI: 1.7–4.4) for ever cigarette smoking, and 0.13 (95% CI: 0.03–0.24) for smoking cessation. Using a clinical definition and volunteers as controls provided respective bipolar disorder adjusted ORs of 7.3 (95% CI: 4.3–12.4), 4.0 (95% CI: 2.4–6.7), and 0.15 (95% CI: 0.06–0.36). Prevalences of current daily smoking for patients with major depression, bipolar disorder, and schizophrenia were 57%, 66%, and 74%, respectively.

Conclusions: Bipolar disorder was associated with significantly higher prevalences of tobacco smoking behaviors compared with the general population or volunteer controls, independently of the definition used. It is possible that smoking behaviors in bipolar disorder may have intermediate prevalences between major depression and schizophrenia,
but larger samples or a combination of multiple studies (meta-analysis) will be needed to establish whether this hypothesis is correct.



Francisco J Diaz 1, Danielle James 2, Sheila Botts 2, Lorraine Maw 2,
Margaret T Susce 2 and Jose de Leon 2,3

1 Department of Statistics, Universidad Nacional, Medellin, Colombia,
2 University of Kentucky, Mental Health Research Center at Eastern State Hospital,
Lexington, KY, USA,
3 Psychiatry and Neurosciences Research Group (CTS-549), Institute of Neurosciences,
University of Granada, Granada, Spain


Corresponding author: Jose de Leon, MD, Mental Health Research Center at Eastern State Hospital, 627 West Fourth Street, Lexington, KY 40508, USA.
Fax: 859-246-7019;
e-mail: jdeleon@uky.edu

Received 7 April 2008, revised and accepted for publication 20 June 2008

Bipolar Disord 2009: 11: 154–165. © 2009
The Authors Journal compilation © 2009
Blackwell Munksgaard

III Jornadas Iberoamericanas en Trastonos Bipolares

Rendimiento Neuropsicologico como predictor de recuperación clínica en pacientes bipolares

Brief report
Neuropsychological performance predicts clinical recovery in bipolar patients

Staci A. Gruber ., Isabelle M. Rosso, Deborah Yurgelun-Todd
Cognitive Neuroimaging Laboratory, Brain Imaging Center, McLean Hospital, and Department of Psychiatry, Harvard Medical School,
115 Mill Street, Belmont, MA 02478, USA

Received 6 October 2006; received in revised form 30 March 2007; accepted 18 April 2007
Available online 23 May 2007


Abstract

Background: Although a number of investigations have reported cognitive deficits in patients with bipolar disorder, relatively few have focused on the relationship between these impairments and clinical outcome.
Methods: In order to help clarify the pattern of and extent to which cognitive deficits are present at the onset of illness and their relationship to outcome, we examined 26 bipolar patients during their first hospitalization and 20 psychiatrically healthy control subjects. All subjects completed tests of frontal/executive control, psychomotor speed and memory function at baseline and selfreports of clinical recovery (time to recover in days) at 12 months post study enrollment.
Results: At baseline, first episode bipolar patients demonstrated greater deficits relative to control subjects on neurocognitive measures, and a significant association was detected between time to recover and performance on a measure of frontal/executive function (interference condition of the Stroop; p=.05; derived interference: p=.04). A trend towards significance was also demonstrated between time to clinical recovery and verbal fluency ( p=.06).
Conclusions: These findings indicate that neuropsychological deficits are seen early in the course of bipolar disorder, prior to the effects of multiple or prolonged episodes, and may be associated with clinical outcome. Future studies are needed to determine whether
changes in inhibitory processing or other cognitive function predict clinical outcome or are associated with treatment response.

© 2007 Elsevier B.V. All rights reserved.
Keywords: Bipolar; Neurocognition; Recovery; Inhibitory function; Stroop

Uso Racional de Ansioliticos y Drogas de Acción Similar

USO RACIONAL DE BENZODIAZEPINA (BZD)

Si bien las BZD están lejos de ser seguras, en las dosis correctas y en el período adecuado, pueden ser fármacos de utilidad terapéutica. Pueden dar a las personas un espacio y tiempo de descanso valioso cuando la crisis emocional es intolerable. Sin embargo, la poderosa cadena de producción, promoción y prescripción distorsiona el uso apropiado de estos medicamentos.
Poseen en común las siguientes propiedades farmacológicas: son ansiolíticas, sedativas, hipnóticas, miorrelajantes y anticonvulsivantes. Son útiles en la medicación preanestésica y, en dosis mayores, como inductores de la anestesia general y mantenimiento de la misma (producen amnesia de la memoria reciente o anterógrada).

Las BZD tienen indicaciones precisas como por ejemplo: en el tratamiento a corto plazo (2 a 4 semanas)29,30,31 de la ansiedad o el insomnio severo, incapacitante o que somete a la persona a una extrema o inaceptable aflicción, y la prescripción debe ir acompañada de otras medidas no farmacológicas, como, en el caso del insomnio, realizar conjuntamente una profilaxis de sueño. En tratamientos prolongados se produce tolerancia al efecto hipnótico.

También están indicadas en la abstinencia alcohólica, y en las crisis de pánico, pero siempre por cortos períodos 32, 33. Son útiles en todo tipo de convulsiones y en las contracturas musculares del tétanos. Se considera que pasadas 2 a 4 semanas de uso se está realizando una sobreutilización de BZD, y el paciente debe ser considerado un consumidor crónico 34.

Las BZD no están indicadas para el tratamiento de la ansiedad presente en la vida cotidiana. Este umbral emocional normal, equivalente a un adecuado estado de alerta, es la más común y universal de las emociones básicas del ser humano y se encuentra presente a lo largo de toda la vida. Permite mejorar el rendimiento y la actividad del individuo. Se la considera patológica sólo cuando es desmedida y/o persistente, planteando un futuro incierto o amenazante que va restringiendo la autonomía, adaptabilidad y el desarrollo personal de quien la sufre.

Las BZD son fármacos de indicación sintomática, no modifican ni el curso ni el pronóstico de las enfermedades, no poseen efectos curativos propiamente dichos, y sólo son útiles en tratamientos a corto plazo debido al desarrollo de tolerancia a sus acciones farmacológicas.

Problemas asociados a la sobreprescripción de las BZD

Su uso crónico puede producir dependencia psíquica y física y ante la supresión brusca pueden desencadenar un síndrome de abstinencia con efectos contrarios a los que producían (efecto “rebote”). El desarrollo del problema suele ser gradual, comenzando con el uso prolongado de BZD para el tratamiento del insomnio y ansiedad, o el consumo diurno para el tratamiento de la ansiedad. En un porcentaje significativo de pacientes el abuso de BZD o el uso crónico ocasiona la aparición de farmacodependencia y adicción con utilización compulsiva y síndrome de abstinencia ante la supresión. Sin embargo esta situación de dependencia suele pasar desapercibida por el médico y por el paciente.
Los efectos clínicos del uso indebido de BZD pueden esquematizarse en dos grandes grupos 35:

• a) reacciones adversas por sobreutilización
• b) farmacodependencia.

a) Reacciones adversas por sobreutilización, sobredosis e incremento de las acciones farmacológicas:

- Excesiva sedación y depresión del sistema nervioso central, (estas acciones son habituales en los usuarios crónicos).

- Debilidad muscular por su acción miorrelajante central.

- Ataxia: incoordinación muscular, pérdida de equilibrio 36,37, efectos típicos de sobredosis que se relacionan con el aumento de los accidentes de tránsito, (tanto de conductores como de peatones).

- Aumento de fracturas de cuello de fémur en personas de edad.

- Disartria y diplopía.

-Somnolencia: sedación permanente, mucho más frecuente en personas de edad avanzada.

- Irregularidades menstruales, ginecomastia, inhibición del orgasmo femenino y como otros depresores del SNC, galactorrea. Aumento de cortisol, prolactina y somatotrofina.

-Efectos neurotóxicos. Relación ventrículo– cerebral anormal. Daños estructurales.

-Reacciones psicoafectivas y emocionales: la administración continuada e irracional ocasiona alteraciones del comportamiento y del sistema vegetativo. Apatía, confusión mental y retardo psicomotor, disminución de la perfomance motora y cognoscitiva.

-Indiferencia afectiva: anestesia emocional. Agravación de depresiones psíquicas reactivas o endógenas: llanto fácil, intensa depresión, agitación psíquica.

-Trastornos de la memoria: Los efectos amnésicos de las benzodiacepinas se utilizan racionalmente en procedimientos de cirugía menor (midazolam y otras BZD de acción ultracorta). Sin embargo puede ocurrir amnesia no deseada importante con cualquier BZD. El lorazepam es uno de los agentes con mayor trastorno amnésico. La amnesia parece ser una consecuencia de una depresión no específica del sistema nervioso central. La habilidad del paciente para manejar o almacenar la información se deteriora marcadamente 38,39, especialmente para elementos aprendidos 2-4 horas antes. Las BZD dificultan la consolidación de la memoria reciente (amnesia anterógrada). Ya en 1968 aparecieron los primeros reportes acerca de importantes alteraciones de la memoria anterógrada consecutivas a la administración de diazepam 40.

- Efectos adversos en el embarazo:
• Útero inhibición, prolongación del parto.
• Dificultades en el ajuste funcional neonatal.
• Depresión respiratoria y síndrome de abstinencia del RN.

Contrariamente a su efecto depresor, en algunas circunstancias pueden ocasionar reacciones paradojales: agitación, euforia, comportamiento violento, reacciones afectivas 41, 42.

El uso de BZD está implicado en muchos problemas sociales y psicológicos como accidentes de tránsito y dificultad para concentrarse en sus tareas habituales. Estos problemas son una carga emocional enorme sobre los individuos y sus familias y constituyen un gasto para los sistemas de salud.

b) Farmacodependencia

En 1961, Hollister y asociados reportan que altas dosis de clordiazepóxido pueden producir síntomas físicos de dependencia, seguidos de un síndrome de abstinencia claramente visible tras la suspensión del tratamiento. Después de esto, el problema de la dependencia a BZD recibió atención exclusivamente a partir de reportes anecdóticos de casos. Recién en la década del 80 se dispuso de mayores datos del carácter, la intensidad, incidencia de la tolerancia, abuso, dependencia, y el síndrome que aparecía tras la discontinuación de la sustancia 43, 44.

Fuente: Valsecia, Mabel. Modulo 4: Uso racional de medicamentos, enfoque racional de la terapéutica de otras patologías en APS / 1° edic. Buenos Aires: Ministerio de Salud de la Nación, 2007. Pag 221-223.

Republica Argentina.

Prevención de Recurrencia y Hospitalizción en Trastono Bipolar I

Preventing recurrence of bipolar I mood episodes and hospitalizations: family psychotherapy plus pharmacotherapy versus pharmacotherapy alone

Solomon, D.A. ab; Keitner, G.I. ab; Ryan, C.E. ab; Kelley, J. b; Miller, I.W. ac

a Department of Psychiatry and Human Behavior, Brown University,
b Rhode Island Hospital,
c Butler Hospital, Providence, RI, USA

Objectives: This study compared the efficacy of three treatment conditions in preventing recurrence of bipolar I mood episodes and hospitalization for such episodes: individual family therapy plus pharmacotherapy, multifamily group therapy plus pharmacotherapy, and pharmacotherapy alone.

Methods: Patients with bipolar I disorder were enrolled if they met criteria for an active mood episode and were living with or in regular contact with relatives or significant others. Subjects were randomly assigned to individual family therapy plus pharmacotherapy, multifamily group therapy plus pharmacotherapy, or pharmacotherapy alone, which were provided on an outpatient basis. Individual family therapy involved one therapist meeting with a single patient and the patient's family members, with the content of each session and number of sessions determined by the therapist and family. Multifamily group psychotherapy involved two therapists meeting together for six sessions with multiple patients and their respective family members, with the content of each session preset. All subjects were prescribed a mood stabilizer, and other medications were used as needed. Subjects were assessed monthly for up to 28 months. Following recovery from the index mood episode, subjects were assessed for recurrence of a mood episode and for hospitalization for such episodes.

Results: Of a total of 92 subjects that were enrolled in the study, 53 (58%) recovered from their intake mood episode. The analyses in this report focus upon these 53 subjects, 42 (79%) of whom entered the study during an episode of mania. Of the 53 subjects who recovered from their intake mood episode, the proportion of subjects within each treatment group who suffered a recurrence by month 28 did not differ significantly between the three treatment conditions. However, only 5% of the subjects receiving adjunctive multifamily group therapy required hospitalization, compared to 31% of the subjects receiving adjunctive individual family therapy and 38% of those receiving pharmacotherapy alone, a significant difference. Time to recurrence and time to hospitalization did not differ significantly between the three treatment groups.

Conclusion: For patients with bipolar I disorder, adjunctive multifamily group therapy may confer significant advantages in preventing hospitalization for a mood episode.


Bipolar Disord 2008: 10: 798–805.
© 2008 The Authors Journal compilation
© 2008 Blackwell Munksgaard

Trastorno Limite de la Personalidad

Evidenced-based pharmacologic treatment of borderline personality disorder: A shift from SSRIs to anticonvulsants and atypical antipsychotics?

Abraham, P.F. a; Calabrese, J.R. b

a 6140 S Broadway, Lorain, OH 44053, USA
b 11400 Euclid Ave, # 200, Cleveland, OH 44106, USA

Received 31 October 2006; received in revised form 24 January 2008; accepted 30 January 2008
Available online 4 March 2008

Objective: The authors performed a review of double-blind, controlled studies of psychotropic drugs to evaluate the evidence base supporting their use in treatment of borderline personality disorder.

Methods: English language literature cited in Medline and published between 1970 and 2006 was searched using the following terms: anticonvulsants, antidepressants, antipsychotics, anxiolytics, benzodiazepines, borderline personality disorder, lithium, medication, mood stabilizers, pharmacotherapy, and psychotropics. Only reports of double-blind, randomized, controlled trials were included.

Results: Twenty eight double-blind, randomized, controlled trials were identified which included anticonvulsants, classical neuroleptics, the benzodiazepine alprazolam, lithium, monoamine oxidase inhibitors, the novel antipsychotic olanzapine, selective serotonin reuptake inhibitors, tricyclic antidepressants, and omega-3 fatty acids. All but three were placebo-controlled. With the exception of alprazolam and tricyclics, the data from these trials revealed evidence of improvements, although often circumscribed and variable. The novel antipsychotic olanzapine appeared to have the most empirical support for having a favorable effect on borderline personality disorder.

Conclusion: A growing body of data suggests that there are psychotropic agents which appear to be well tolerated, and which to varying degrees may be expected to ameliorate the domains of psychopathology associated with borderline personality disorder. The research literature, on which practice should be optimally based, appears to suggest a need for a shift from antidepressants to anticonvulsants and atypical antipsychotics.


Journal of Affective Disorders 111 (2008) 21–30
© 2008 Elsevier B.V. All rights reserved.