Abstract Introduction Suicide among physicians constitutes a public health problem that deserves more consideration. A recently performed meta-analysis and systematic review evaluated suicide mortality in physicians by gender and investigated several related risk factors. It showed that the post-1980 suicide mortality was 46% higher in female physicians than among women in the general population, while the risk in male physicians was 33% lower than among men in general, despite an overall contraction in physician mortality rates in both genders. Methods This narrative review was conducted by searching and analyzing articles/databases that were relevant to addressing questions raised by a prior meta-analysis and how they might be affected by COVID-19. This process included unstructured searches on Pubmed for physician suicide, burnout, judicialization of medicine, healthcare organizations, and COVID-19, and Google searches for relevant databases and medical society, expert, and media commentaries on these topics. We focus on three factors critical to addressing physician suicides: epidemiological data limitations, psychiatric comorbidities, and professional overload. Results We found relevant articles on suicide reporting, physician mental health, the effects of healthcare judicialization, and organizational involvement on physician and patient health, and how COVID-19 may impact such factors. This review addresses information sources, underreporting/misreporting of physician suicide rates, inadequate diagnosis and management of psychiatric comorbidities and the chronic effects on physicians’ work capacity, and, finally, judicialization of medicine and organizational failures increasing physician burnout. We discuss these factors in general and in relation to the COVID-19 pandemic. Conclusions We present an overview of the above factors, discuss possible solutions, and specifically address how COVID-19 may impact such factors. consideration metaanalysis meta analysis post1980 post 1980 post-198 46 population 33 genders articlesdatabases COVID19. COVID19 COVID 19. 19 burnout organizations COVID19, 19, society expert topics suicides limitations overload reporting COVID-1 sources underreportingmisreporting underreporting misreporting capacity finally pandemic solutions post198 198 post-19 4 3 COVID1 1 COVID- post19 post-1 post1 post-

Objective: To identify suicide rates and how they relate to demographic factors (sex, race and ethnicity, age, location) among physicians compared to the general population when aggravated by the coronavirus disease 2019 (COVID-19) pandemic. Methods: We searched U.S. databases to report global suicide rates and proportionate mortality ratios (PMRs) among U.S. physicians (and non-physicians in health occupations) using National Occupational Mortality Surveillance (NOMS) data and using Wide-ranging Online Data for Epidemiologic Research (WONDER) in the general population. We also reviewed the effects of age, suicide methods and locations, COVID-19 considerations, and potential solutions to current challenges. Results: Between NOMS1 (1985-1998) and NOMS2 (1999-2013), the PMRs for suicide increased in White male physicians (1.77 to 2.03) and Black male physicians (2.50 to 4.24) but decreased in White female physicians (2.66 to 2.42). Conclusions: The interaction of non-modifiable risk factors, such as sex, race and ethnicity, age, education level/healthcare career, and location, require further investigation. Addressing systemic and organizational problems and personal resilience training are highly recommended, particularly during the additional strain from the COVID-19 pandemic.

RESUMO Objetivos Avaliar a depressão e a qualidade de vida em indivíduos com doença de Stargardt (DS), distrofia macular cuja perda de visão central se inicia nas primeiras décadas de vida. Métodos Este estudo observacional e transversal incluiu 41 pacientes com DS e 46 controles saudáveis, com idades entre 18 e 63 anos, em Minas Gerais, Brasil. Episódio de depressão maior foi avaliado pelo Mini Internacional Neuropsychiatric Interview (MINI)-PLUS, a sintomatologia depressiva, pelo Inventário de Depressão de Beck (BDI) e pela Escala de Depressão de Hamilton (HAM-D) e a qualidade de vida, pelo Questionário de Função Visual do Instituto de Olhos Nacional versão de 25 itens (NEI VFQ-25). A comparação entre as variáveis sociodemográficas, a qualidade de vida e a depressão foi realizada por meio do teste exato de Fisher e o teste de Mann-Whitney-Wilcoxon. Resultados A prevalência de depressão foi de 12,2% na amostra com indivíduos com DS, enquanto no grupo controle foi de 8,7% (p = 0,614). Não foram observadas diferenças significativas entre os pacientes e o grupo controle quanto à prevalência de depressão e às variáveis sociodemográficas. Os pacientes com DS apresentaram menor pontuação geral de qualidade de vida (59,7 vs. 88,7, p < 0,001), cujas variáveis com correlação inversa e estatisticamente significante (p < 0,05) foram as de sintomatologia depressiva, avaliadas pelo BDI ( Rho = -0,49, p < 0,001) e pelo HAM-D ( Rho = -0,45, p = 0,003). Conclusão Os sintomas depressivos foram os principais fatores que afetaram a qualidade de vida, independentemente dos dados sociodemográficos. Indivíduos com DS podem desenvolver estratégias de enfrentamento e procurar assistência mental para evitar o aumento da depressão e a diminuição da qualidade de vida.

ABSTRACT Objectives To assess depression and quality of life in individuals with Stargardt’s disease (SD), macular dystrophy whose central vision loss begins in the first decades of life. Methods This observational, cross-sectional study included 41 SD patients and 46 healthy controls, aged 18 to 63 years old, in Minas Gerais, Brazil. Major depression episode was assessed by the Mini International Neuropsychiatric Interview, depressive symptomatology by the Beck Depression Inventory (BDI) and Hamilton Depression Scale (HAM-D) and quality of life by the National Eye Institute Visual Function Questionnaire. The comparison between sociodemographic variables, quality of life and depression was performed using Fisher’s exact test and Mann-Whitney-Wilcoxon test. Results The prevalence of depression was 12.2% in the sample with SD while in the control group was 8.7% (p = 0.614). No significant differences were observed between patients and the control group regarding the prevalence of depression and sociodemographic variables. Patients with SD had overall lower quality of life scores (59.7 vs. 88.7, p < 0.001), and presented inverse correlation between depressive symptoms, as assessed by BDI (Rho = -0.49, p < 0.001) and by HAM-D (Rho = -0.45, p = 0.003) with quality of life scores. Conclusion Depressive symptoms were the major factors affecting quality of life, regardless of sociodemographic data. Individuals with SD may develop copying strategies, seek mental care to prevent the increase of depression and decrease of quality of life.

Resumo Introdução: A análise fatorial da Escala de Depressão Pós-Parto de Edimburgo (Edinburgh Postnatal Depression Scale, EPDS) poderia resultar em uma ferramenta de triagem mais curta e mais fácil de aplicar. Portanto, o objetivo deste estudo foi verificar e comparar as métricas de duas subescalas EPDS de 6 itens. Métodos: Administramos a EPDS a um total de 3.891 mulheres que deram à luz entre 1 e 3 meses antes da aplicação. Foram realizadas análises fatoriais confirmatórias e exploratórias e geradas curvas ROC (receiver-operating characteristics) para determinar, respectivamente, a validade do construto, o ajuste dos itens da escala aos dados, e os pontos de corte ideais para as versões curtas. Resultados: A escala de 6 itens previamente publicada não apresentou validade de construto para nossa amostra. No entanto, utilizamos a análise fatorial exploratória para derivar uma nova escala de 6 itens, que apresentou boa validade de construto. A área sob a curva ROC da nova escala de 6 itens foi 0,986, e o ponto de corte ideal foi ≥ 6. Conclusão: A nova escala de 6 itens possui propriedades psicométricas adequadas e valores de curva ROC semelhantes à versão de 10 itens e oferece um meio de reduzir o custo e o tempo necessário para administrar o instrumento.

Abstract Introduction: Factor analysis of the Edinburgh Postnatal Depression Scale (EPDS) could result in a shorter and easier to handle screening tool. Therefore, the aim of this study was to check and compare the metrics of two different 6-item EPDS subscales. Methods: We administered the EPDS to a total of 3,891 women who had given birth between 1 and 3 months previously. We conducted confirmatory and exploratory factor analyses and plotted receiver-operating characteristics (ROC) curves to, respectively, determine construct validity, scale items' fit to the data, and ideal cutoff scores for the short versions. Results: A previously defined 6-item scale did not exhibit construct validity for our sample. Nevertheless, we used exploratory factor analysis to derive a new 6-item scale with very good construct validity. The area under the ROC curve of the new 6-item scale was 0.986 and the ideal cutoff score was ≥ 6. Conclusions: The new 6-item scale has adequate psychometric properties and similar ROC curve values to the10-item version and offers a means of reducing the cost and time taken to administer the instrument.

RESUMO Objetivo A depressão maior tem sido associada a alterações nos níveis de cortisol e dehidroepiandrosterona (DHEA) em pacientes idosos depressivos. O presente estudo objetivou investigar a associação entre depressão, cortisol e DHEA, corrigindo por variáveis intervenientes, incluindo a capacidade física. Além disso, a associação entre os níveis hormonais e a capacidade física nos dois grupos experimentais também foi analisada. Método Pacientes idosos depressivos (n = 32) e idosos controles saudáveis (n = 31), pareados pela idade foram analisados. Os sujeitos foram submetidos a uma avaliação da capacidade física, incluindo níveis de atividade física, testes de capacidade funcional e escalas de equilíbrio. Resultados Os pacientes depressivos mostraram níveis significativamente menores de cortisol, os quais tornaram-se não significantes após controlados pela capacidade física. Uma correlação positiva foi observada entre os níveis de cortisol e a capacidade física. Resultados não significativos foram observados para DHEA, possivelmente devido a inclusão de pacientes depressivos e uma única coleta de amostra. Conclusão Os dados sugerem que a capacidade física modula a relação entre depressão e os níveis de cortisol e deve ser considerada em futuras investigações.

ABSTRACT Objective Major depression have been associated with cortisol and dehydroepiandrosterone (DHEA) changes in old depressed patients. We examined the association between depression, cortisol, and DHEA, correcting for confounding variables, including physical capacity. In addition, the association between hormone levels and physical capacity in these two experimental groups was also analyzed. Method Depressed patients (n = 32) and healthy control (n = 31) old adults, both matched for age, were analyzed. Subjects were submitted to a physical capacity evaluation, including physical activity levels, functional fitness test, and balance scale. Results Depressed patients showed significant lower levels of cortisol than controls, which became non-significant after controlling for physical capacity. A positive correlation was observed between cortisol levels and physical capacity. Conclusions The data suggest that physical capacity modulates the relationship between depression and cortisol levels and needs to be taken into consideration in the future investigations.

Objective: Approximately one-half of all patients affected by bipolar disorder present with psychotic features on at least one occasion. Several studies have found that alterations in the activity of mesolimbic and prefrontal regions are related to aberrant salience in psychotic patients. The aim of the present study was to investigate the structural correlates of a history of hallucinations in a sample of euthymic patients with bipolar I disorder (BD-I). Methods: The sample consisted of 21 euthymic patients with BD-I and no comorbid axis I DSM-IV-TR disorders. Voxel based morphometry (VBM) was used to compare patients with and without a lifetime history of hallucinations. Preprocessing was performed using the Diffeomorphic Anatomical Registration through Exponentiated Lie Algebra (DARTEL) algorithm for VBM in SPM8. Images were processed using optimized VBM. Results: The main finding of the present study was a reduction in gray matter volume in the right posterior insular cortex of patients with BD-I and a lifetime history of hallucinations, as compared to subjects with the same diagnosis but no history of hallucinations. Conclusions: This finding supports the presence of abnormalities in the salience network in BD patients with a lifetime history of hallucinations. These alterations may be associated with an aberrant assignment of salience to the elements of one’s own experience, which could result in psychotic symptoms.

Objective: The Barratt Impulsiveness Scale (BIS-11) is a valid and reliable instrument, and one of the most often used tools to assess impulsivity. This study assesses the performance of a large sample of adults by using a version of BIS-11 adapted to Brazilian Portuguese. Methods: We assessed 3,053 adults from eight Brazilian states. Internal consistencies and performance data were presented for two correction criteria of BIS-11: original and the two-factor score. Results: The associations between age, sex, region, and education and the BIS-11 scores present very small effect sizes. Therefore, we provided a percentile rank parameter for the different BIS-11 subscores considering the whole sample. Given the internal consistency of the two correction systems, we found that only the two-factor system fulfills the psychometric criteria of Cronbach’s alpha (cutoff value of at least 0.6). Conclusion: Our results support the use of the Brazilian adaptation of BIS-11 in different regions of the country as a measure of impulsivity. Since high impulsiveness is a characteristic of several dysfunctional behaviors, the establishment of normative parameters is of utmost relevance and should be extended to other age ranges and populations in future studies.

Background: Sensorimotor deficits are an important phenomenological facet observed in patients with bipolar disorder (BD). However, there is little research on this topic. We hypothesize that the MPraxis test can be used to screen for motor impairments in BD aiming movements. Method: The MPraxis, which is a quick and easy-to-apply computerized test, measures sensorimotor control. During the test, the participant must move the computer mouse cursor over an ever-shrinking green box and click on it once. We predict that the MPraxis test is capable of detecting differences in sensorimotor performance between patients with BD and controls. We assessed 21 euthymic type I BD patients, without DSM-IV-TR Axis I comorbidity, and 21 healthy controls. Results and conclusions: Compared to the controls, the patients with BD presented a lower response time in their movements in all conditions. Our results showed sensorimotor deficits in BD and suggested that the MPraxis test can be used to screen for motor impairments in patients with euthymic BD.

Em todo o mundo, pesquisas sobre a fecundidade efetivada na segunda década da vida demonstram que jovens mães completam menos anos de escolarização se comparadas com pares etárias nulíparas ou, ainda, com mulheres que postergam o nascimento do primeiro filho para os 20 ou mais anos de idade. No Brasil, poucos estudos identificaram em que medida os diferenciais observados já estavam presentes antes da fecundidade e, por essa razão, torna-se difícil avaliar os efeitos do nascimento de um filho sobre as carreiras escolares das jovens mães. O presente estudo analisou a trajetória escolar de uma amostra representativa (n=225) para uma coorte de mães adolescentes residentes em Campinas, município com mais de 1 milhão de habitantes, localizado no Estado de São Paulo. Todas as jovens da amostra tiveram seu primeiro filho nascido vivo entre as idades de 17 e 19 anos no ano de 2005 e foram entrevistadas entre 2006 e 2007. Os anos de estudos concluídos foram mensurados por meio de uma observação transversal e pós-fecundidade. No entanto, a partir de questões retrospectivas, as histórias escolares das jovens mães foram reconstituídas longitudinalmente desde os 7 até os 16 anos, idades em que todas eram nulíparas. As elevadas proporções de repetências e interrupções em período anterior à gravidez e também ao nascimento do primeiro filho das jovens amostradas indicam que muitas tiveram suas histórias escolares cingidas por obstáculos que ultrapassam a questão da fecundidade: 28,0% repetiram de série e interromperam suas carreiras escolares, enquanto 78,2% repetiram ou evadiram ao menos uma série antes da gravidez e do nascimento do primeiro filho. Concluiu-se que, em função da metodologia adotada, estudos transversais que analisam os déficits educacionais das jovens mães somente após a fecundidade e os comparam diretamente com os anos de estudo alcançados por mulheres sem filhos - ou com aquelas que alcançaram a fecundidade após completarem 20 anos de idade - podem não identificar adequadamente a origem temporal da defasagem idade-série usualmente observada.

Worldwide research on fertility in the second decade of life has shown that young mothers complete fewer years of schooling than their nulliparous age peers and women who postpone their first childbirth until age 20 or later. In Brazil, few studies have identified the extent to which these gaps were already present before fertility. Thus, it is difficult to assess the real effect of pregnancy and fertility on young mothers’ education. This paper comprises an analysis of the educational progress of a representative sample (n = 225) of young women living in Campinas, a municipality of one million inhabitants in the state of Sao Paulo, Brazil. All individuals in the sample had their first live-born child between the ages of 17 and 19 in 2005 and were interviewed between 2006 and 2007. Their schooling histories from age seven to 16 (when all were still nulliparous) were then reconstituted longitudinally by the use of retrospective questions. The high incidence of academic failures and interruptions in studies prior to the subjects’ pregnancies and first live births indicates that many of them had encountered obstacles in their schooling career before fertility: 28.0% failed and dropped out while 78.2% failed or dropped out of at least one school grade before pregnancy and their first live birth. Thus, cross-sectional studies that analyze the schooling deficits of young mothers only after their first pregnancy or childbirth and directly compare them to the school achievements of childless women-or those who delayed their first childbirth after the age of 20-may not properly identify the origins of age-school grade gaps and the few years of schooling completed.

Alguns estudos investigaram a possível relação entre tentativas de suicídio e impulsividade em pacientes com transtorno bipolar. O objetivo do estudo foi avaliar a relação entre características neuropsicológicas e clínicas e o comportamento suicida em pacientes bipolares eutímicos. Utilizamos o Iowa Gambling Task e o Conner's Continuous Performance Test para avaliar a impulsividade em 95 pacientes eutímicos com transtorno bipolar (42 com tentativas de suicídio) e 155 controles normais. Uma análise fatorial avaliou a adequação dos instrumentos e foi criado um modelo para previsão do número de tentativas de suicídio usando regressão linear múltipla. Nossos resultados apontam para um tipo específico de impulsividade relacionada à tomada de decisões, falta de planejamento e para a comorbidade Transtorno de Personalidade Borderline. A impulsividade por não planejamento é um fator de risco para tentativas de suicídio em pacientes com Transtorno Bipolar.

Some studies have investigated the possible relationship between suicide attempts and impulsivity in patients with bipolar disorder. The objective of this study was to assess the relationship between neuro-psychological and clinical aspects and suicide behavior in euthymic bipolar patients. The Iowa Gambling Task and the Conner's Continuous Performance Test evaluated impulsivity in 95 euthymic bipolar patients - 42 suicide attempters and 115 normal control participants. A factorial analysis evaluated the adequacy of the instruments. Furthermore, a multiple regression analysis was done in order to develop a model to predict suicide attempts. Our results point to a specific type of impulsivity related to making decisions, lack of planning and borderline personality disorder comorbidity. This type of impulsivity is a risk factor for suicide attempts in patients with bipolar disorder.

OBJETIVO: Avaliar o processo de tomada de decisão em pacientes com transtorno obsessivo-compulsivo (TOC) utilizando o Iowa Gambling Task. Pretende-se, também, avaliar características demográficas e clínicas que possam influenciar essa função executiva. MÉTODO: Nossa amostra é composta de 214 sujeitos (107 pacientes com diagnóstico de TOC e 107 controles) que foram avaliados do ponto de vista clínico, demográfico e neuropsicológico. O Iowa Gambling Task, um teste que avalia o processo de tomada de decisão, foi aplicado. RESULTADOS: Observamos um prejuízo no desempenho dos pacientes com TOC no IGT. Características como sintomas depressivos e ansiosos não foram responsáveis por esse prejuízo. CONCLUSÃO: O prejuízo no processo de tomada de decisão parece ser um componente importante na fisiopatologia do TOC. Como o TOC é um transtorno heterogêneo, grupos mais homogêneos são necessários para uma melhor caracterização e confirmação dos nossos achados.

OBJECTIVE: This study aims to evaluate the process of decision-making in patients with obsessive-compulsive disorder (OCD) using the Iowa Gambling Task (IGT). In addition, we intend to expand the understanding of clinical and demographic characteristics that influence decision-making. METHOD: Our sample consisted of 214 subjects (107 diagnosed with OCD and 107 healthy controls) who were evaluated on their clinical, demographic and neuropsychological features. Moreover, the Iowa Gambling Task (IGT), a task that detects and measures decision-making impairments, was used. RESULTS: We found that OCD patients performed significantly worse on the IGT. Furthermore, features such as symptoms of anxiety did not influence IGT performance. CONCLUSION: Impaired decision-making seems to be a key feature of OCD. Given that OCD is a complex heterogeneous disorder, homogeneous groups are necessary for an accurate characterization of our findings.

OBJETIVO: Diversos estudos demonstram que o transtorno obsessivo-compulsivo apresenta considerável contribuição genética, com diversos genes candidatos tendo sido estudados por meio de estudos de associação. Como alterações do sistema serotonérgico estão associadas ao transtorno obsessivo-compulsivo, o gene da triptofano hidroxilase 2, enzima limitante da síntese da serotonina, é plausível candidato para estudos. MÉTODO: Nossa amostra é composta de 321 sujeitos (107 pacientes com transtorno obsessivo-compulsivo e 214 controles) e investigamos oito tagSNPs (rs4448731, rs4565946, rs11179000, rs7955501, rs10506645, rs4760820, rs1487275 e rs10879357) do gene da triptofano hidroxilase 2. Análise estatística foi realizada com os programas UNPHASED e Haploview. RESULTADOS: Análise de frequência alélica e genotípica entre casos e controles não evidenciaram diferenças estatisticamente significativas. No entanto, observamos maior prevalência dos haplótiposT-C-T (rs4448731, rs4565946, rs10506645) e C-A-T (rs4565946, rs7955501, rs10506645) entre os pacientes, assim como duas regiões com importantes desequilíbrios de ligação (SNPs rs4448731 e rs4565946; SNPs rs10506645 e 4760820). DISCUSSÃO: Nossos achados não demonstraram uma associação entre os SNPs do gene da TPH2 e o transtorno obsessivo-compulsivo, porém mais estudos são necessários, já que fortes desequilíbrios de ligação foram demonstrados, assim como dois haplótipos.

OBJECTIVE: A substantial body of evidence suggests that obsessive-compulsive disorder has a genetic component, and substantial candidate genes for the disorder have been investigated through association analyses. A particular emphasis has been placed on genes related to the serotonergic system, which is likely to play an important role in the pathogenesis of obsessive-compulsive disorder. The gene for tryptophan hydroxylase 2, which is a rate limiting enzyme in serotonin synthesis is considered an important candidate gene associated with psychiatric disorders. METHOD: Our sample consisted of 321 subjects (107 diagnosed with obsessive-compulsive disorder and 214 healthy controls), which were genotyped for eight tagSNPs (rs4448731, rs4565946, rs11179000, rs7955501, rs10506645, rs4760820, rs1487275 and rs10879357) covering the entire human tryptophan hydroxylase 2 gene. Statistical analyses were performed using UNPHASED, version 3.0.12, and Haploview ((R)). RESULTS: Single markers, genotype analysis did not show a significant genetic association with obsessive-compulsive disorder. A significant association between the T-C-T (rs4448731, rs4565946, rs10506645) and C-A-T (rs4565946, rs7955501, rs10506645) haplotypes and obsessive-compulsive disorder was observed, as well as a strong linkage disequilibrium between SNPs rs4448731 and rs4565946, and SNPs rs10506645 and 4760820. DISCUSSION: Our research has not demonstrated the existence of associations between the eight SNPs of TPH2 and obsessive-compulsive disorder. However, two LD and two haplotypes areas were demonstrated, thus suggesting that more studies in TPH2 are needed to investigate the role of tryptophan hydroxylase 2 variants in obsessive-compulsive disorder.