Personality dimensions, resilience, and depression during COVID-19 pandemic: A one-year longitudinal study

BACKGROUND

The onset of the COVID-19 pandemic has brought to light a significant surge in depression across diverse populations. While a considerable body of research has linked this upswing to lockdowns and restrictive measures, it is crucial to recognize that lockdowns alone cannot fully elucidate the observed increase in mental health disorders, given the vast array of individual psychological responses.

OBJECTIVE

This study aims to test e whether personality dimensions (Extroversion, Neuroticism, and Psychoticism) and resilience play a role in shielding individuals from developing depression during the COVID-19 pandemic, as observed in a sample of Brazilian adults.

METHODS

This research employed a one-year longitudinal naturalistic study involving the general population. It utilized a web-based questionnaire administered in three waves during the COVID-19 pandemic: April 2020, September 2020, and May 2021. The research protocol contains the Patient Health Questionnaire-9 - PHQ-9, the Connor-Davidson Resilience Scale - CD-RISC, and the Eysenck Personality Questionnaire Revised-Abbreviated - EPQR-A.

RESULTS

Our study encompassed 455 participants, of which 35.6 % met the criteria for depression in the first wave, and this figure decreased to 18.5 % in the second and third waves (p = 0.001). Resilience levels in the non-depressed group (consistently exhibited higher means across all three waves when compared to the depressed group (first wave: x¯= 27.98; second wave: x¯= 37.26; third wave: x¯= 36.67; p = 0.001). Furthermore, resilience exhibited an overall protective effect against depression in all waves (PR = 0.93, p = 0.000). Neuroticism and Psychoticism emerged as predictors of depression across all waves (PR = 1.346; p = 0.0001 and PR = 1.157; p = 0.030), while the Extroversion dimension showed no significant effect.

CONCLUSION

The decline in depression rates during the first year of the COVID-19 pandemic was influenced by levels of resilience, which acted as a protective factor against the development of depressive symptoms. Notably, Neuroticism and Psychoticism predicted the risk of developing depressive symptoms. Implications for practical intervention in future crisis scenarios suggest the need for public health policy programs featuring personalized interventions that prioritize enhancing resilience.

The Eysenck Personality Questionnaire Revised - Abbreviated (EPQR-A): psychometric properties of the Brazilian Portuguese version

INTRODUCTION

The Eysenck Personality Questionnaire Revised - Abbreviated (EPQR-A) consists of 24 items for assessment of the three fundamental personality traits (psychoticism, extraversion, and neuroticism) and a validity scale (lie scale). Our objectives were to assess the psychometric properties of a version of this instrument culturally adapted for Brazil.

METHOD

321 participants were recruited using a non-probabilistic method.

RESULTS

Internal consistencies ranged from minimally acceptable to respectable, except for the psychoticism domain. Higher neuroticism scores were associated with higher depression and anxiety scores, higher extraversion scores were associated with lower levels of depression symptoms, and higher psychoticism scores were associated with higher levels of depression symptoms.

CONCLUSION

Our findings describe sustainable psychometric properties for the Brazilian Portuguese version of EPQR-A.

Serum cytokine variations among inpatients with major depression, bipolar disorder, and schizophrenia versus healthy controls: a prospective 'true-to-life' study

BACKGROUND

There is increasing evidence of the association between chronic low-grade inflammation and severe mental illness (SMI). The objective of our study was to assess serum cytokine levels (SCLs) at admission and discharge in a true-to-life-setting population of inpatients with major depression (MD), bipolar disorder (BD), and schizophrenia (Sz), as well as of healthy controls.

METHODS

We considered MD, BD, and Sz to be SMIs. We evaluated 206 inpatients [MD, N = 92; BD, N = 26; mania (Ma), N = 44; Sz, N = 44). Generalized estimating equations were used to analyze variations in SCL [interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin (IL)-2, IL-4, IL-6, IL-10, and IL-17] at hospital admission and discharge. Results of 100 healthy controls were compared with those of SMI patients at both time points. We evaluated patients' improvement during in-hospital treatment in terms of general psychiatric symptoms, global clinical impression, functionality, and manic and depressive symptoms with validated scales.

RESULTS

In all, 68.9% of patients completed the study. Overall, SMI inpatients had higher SCL when compared with controls regardless of diagnosis. There was a significant decrease in Brief Psychiatric Rating Scale (BPRS) and Clinical Global Impression-Severity Scale (CGI-S) scores, and an increase in Global Assessment of Functioning (GAF) scores for all disorders evaluated (p < 0.001), as well as a significant decrease in HDRS-17 scores among MD inpatients (p < 0.001) and in YMRS scores among Ma inpatients (p < 0.001). IL-2 and IL-6 levels decreased significantly between admission and discharge only among MD inpatients (p = 0.002 and p = 0.03, respectively). We found no further statistically significant changes in SCL among the remaining disorders (BD, Ma, and Sz). There was no significant decrease in IFN-γ (p = 0.64), TNF-α (p = 0.87), IL-4 (p = 0.21), IL-10 (p = 0.88), and IL-17 (p = 0.71) levels in any of the evaluated diagnoses.

CONCLUSION

MD inpatients had a decrease in IL-2 and IL-6 levels during hospitalization, which was accompanied by clinical improvement. No associations were found for the remaining SMIs (BD, Ma, and Sz).

Structural magnetic resonance imaging findings in severe mental disorders adult inpatients: A systematic review

In severe presentations, major depressive disorder (MDD), schizophrenia (SZ), and bipolar disorder (BD) can be categorized as severe mental disorders (SMD). Our aim is to evaluate structural magnetic resonance imaging and computed tomography findings in adult inpatients diagnosed with SMD and hospitalized at psychiatric wards. PubMed, Embase, PsycInfo, Cochrane Library, and Web of Science were searched up to May 27th, 2021. Articles were screened and extracted by two independent groups, with third-party raters for discrepancies. Quality of evidence was evaluated with the Newcastle-Ottawa Scale. Synthesis was made by qualitative analysis. This study was registered on PROSPERO (CRD42020171718) and followed the PRISMA protocol. 35 studies were included, of which none was considered to likely introduce bias in our analyses. Overlapping areas in MDD, SZ, and Affective Psychosis (AP) patients, that include BD and MDD with psychotic features, are presented in the inferior temporal and cingulate gyri. MDD and SZ had commonly affected areas in the inferior and middle frontal gyri, transverse temporal gyrus, insula, and hippocampus. SZ and AP had commonly affected areas in the temporal pole. Overlapping affected areas among SMD patients are reported, but the heterogeneity of studies' designs and findings are still a limitation for clinically relevant guidelines.

Protective factors against depressive symptoms among Brazilian healthcare workers during the initial stages of the COVID-19 pandemic: a cross-sectional study

OBJECTIVES

This study aims to assess the prevalence of depressive symptoms among healthcare workers and possible factors associated with this outcome (resilience, spirituality, social support, quality of life, among other individual variables). Our hypothesis is that some of these factors can have a protective effect on depressive symptoms.

DESIGN

Web-based cross-sectional survey.

SETTING

Participants were recruited online from 16 April to 23 April 2020.

PARTICIPANTS

1043 healthcare workers, predominantly Brazilians, aged 18 years or older.

PRIMARY AND SECONDARY OUTCOME MEASURES

Depression was the primary outcome, measured using the Patient Health Questionnaire-9 (PHQ-9). Possible protective factors were measured in the following ways: social support was assessed by the modified Medical Outcomes Study Social Support Survey (mMOS-SS); spirituality, religiousness and personal beliefs (SRPB) were evaluated using the 9-item SRPB module of the brief WHO Quality of Life instrument (WHOQoL-SRPB-bref); quality of life was assessed using the brief EUROHIS instrument for Quality of Life (EUROHIS-QoL 8-item); resilience was assessed using the 10-item Connor-Davidson Resilience Scale (CD-RISC 10).

RESULTS

23% met the criteria for depression according to the PHQ-9 scale. Quality of life (B=-3.87 (-4.30 to -3.43), β=-0.37, p<0.001), social support (B=-0.32 (-0.59 to -0.05), β=-0.04, p=0.022), resilience (B=-0.19 (-0.23 to -0.15), β=-0.20, p<0.001), SRPB (B=-0.03 (-0.05 to -0.02), β=-0.01, p<0.001) and physical exercise (B=-0.95 (-1.40 to -0.51), β=-0.08, p<0.001) demonstrated protective effects against depression.

CONCLUSION

Healthcare workers have a high risk of developing depressive symptoms during the COVID-19 pandemic, especially those working in the front line. However, there are factors that seem to work as protective mechanisms against depression, notably perceived quality of life.

Time series analysis of suicide from a monthly perspective in the south of Brazil: an ecological study

INTRODUCTION

Suicide is the cause of death of almost 800 thousand people worldwide every year. In Brazil, Rio Grande do Sul is one of the states with the highest suicide rates. This study aimed to assess whether there is a significant monthly time pattern of suicide in Rio Grande do Sul, by gender and age ranges, and whether suicide characteristics in the state are coherent with findings from previous studies.

METHODS

All data were collected from official secondary sources maintained by the national Brazilian and Rio Grande do Sul governments, covering a period from 2015 to 2019. Data included suicide deaths and population, divided by gender and age range. Sum totals, frequencies, odds ratios, and time series analyses were performed.

RESULTS

From 2015 to 2019, 6,287 people committed suicide in Rio Grande do Sul. Most of them were men and the most prevalent age band was from 50 to 59 years old. Men had higher suicide rates then women in all age ranges (p < 0.001) and in all months of the year, with an approximately 4-fold higher risk of committing suicide when compared to women. Men had a trending peak of suicide in January and December (p < 0.001), whereas women's suicide rates peaked in March and December (p = 0.001).

CONCLUSION

There are monthly time trends and seasonal patterns of suicide rates in Rio Grande do Sul, varying by gender and age range. Gender differences occurred mainly in the first three months of the year, and the age pattern was more evident among individuals aged 60 years or older.

Brain-derived neurotrophic factor (BDNF) and inflammatory markers: Perspectives for the management of depression

BACKGROUND

Mood disorders, including major depressive disorder, are among the main causes of disability and early mortality and constitute an important public health problem. Despite the search for a neurobiological explanation for these disorders, diagnosis and treatment are still based on subjective symptoms and psychometric assessments. Biomarkers, used as indicators of normal biological and pathological processes or pharmacological responses to a clinical intervention, may be useful in improving the current classification of psychiatric disorders, which can help understand the role of biological information in diagnosis, prognosis, and assessment of responses to intervention.

OBJECTIVES

This review aims to analyze the existing literature on Brain-Derived Neurotrophic Factor (BDNF) and inflammatory markers related to depression and to assess the advances and perspectives of their applicability in the diagnosis, prognosis, and assessment of responses to intervention in order to understand the importance of these biomarkers for the management of depression.

RESULTS

Evidence shows that BDNF is an important biomarker for the pathogenesis of depression; reduced levels are linked to reduced synaptic plasticity and neuronal atrophy, while elevated levels are associated with survival and neuronal differentiation, which is compatible with the neurogenic hypothesis of depression. Although the use of this biomarker is not yet established, literature shows that the concentration of BDNF is a useful measure for the differentiation between healthy and depressed individuals. Based on the inflammatory theory of depression, studies have found higher levels of inflammation in depressed individuals when compared to healthy ones, as well as an association between chronic inflammation and depressive symptoms. Studies have also found anti-inflammatory agents with anti-depressant effects. Markers such as IL-6, IL-1β, TNFα, and C-reactive protein (CRP) are potential markers of depression, but the role of cytokines in human brain activity is still insufficiently established.

CONCLUSIONS

Despite the large number of potential biological markers not yet fully established in the pathophysiology of depression, which is a challenge for psychobiology, it is clear that the concentrations of these substances are altered in psychiatric diagnoses related to the disease activity. Thus, although more research is needed, the current body of knowledge on biomarkers allows us to predict their use in the management of depression.

Positive Association Between Therapeutic Alliance and Quality of Life in Psychodynamic Psychotherapy, Cognitive Behavior Therapy, and Interpersonal Therapy: The Patient's Perspective

BACKGROUND

The therapeutic alliance (TA) is considered a common psychotherapeutic factor associated with positive results in psychotherapies. There are no studies relating the TA with quality of life (Qol).

OBJECTIVES

Our objective was to evaluate whether there is an association between the TA and Qol across three different psychotherapies.

METHODS

A cross-sectional study, which included outpatients undergoing individual psychotherapeutic treatment was conducted. When analyzing the total sample, the correlation of the TA with Qol domains did not present statistical significance. When considering only the sample of patients who were undergoing treatment in psychodynamic psychotherapy (PP), there was a statistically significant association between the TA and the psychological domain of Qol (p < 0.05). When using a regression model for adjusting for confounding factors, the association between psychological domain with the TA on the PP patients sample lost significance (p = 0.221).

DISCUSSION

These findings suggest that the TA seems to be more strongly related to better QoL in PP.

Different cytokine patterns associate with melancholia severity among inpatients with major depressive disorder

BACKGROUND

Six melancholic features (MFs) of the Hamilton Depression Rating Scale (HAM-D6) represent the construct of melancholia along a continuum of severity (from least to most severe: depressed mood, work and activities, somatic symptoms, psychic anxiety, guilty feelings, psychomotor retardation). We aimed to evaluate the association between these MFs and inflammatory cytokines (IC) in the blood.

METHODS

Each IC [interferon gamma (IFN-γ), tumor necrosis factor alpha (TNF-α), interleukin 2 (IL-2), IL-4, IL-6, IL-10, and IL-17] was associated with the HAM-D6 MFs of 139 severely depressed inpatients, using multiple linear regressions adjusted for covariates. Levels were compared with those of 100 healthy controls.

RESULTS

Depressed mood was associated with higher levels of IL-4 (β = 0.167; p = 0.041). Psychic anxiety: lower IL-17 levels (β = -0.173; p = 0.039). Guilt feelings: lower IL-2 levels (β = -0.168; p = 0.041) Psychomotor retardation: higher IL-6 levels (β = 0.195; p = 0.017). Depressed patients' TNF-α, INF-γ, and IL-4 levels were not significantly different from controls. Depressed patients' IL-2, IL-6, IL-10, and IL-17 levels were higher than those of controls (p <0.001).

CONCLUSION

Less severe MFs (depressed mood, psychic anxiety, and guilt feelings) were associated with an anti-inflammatory pattern (higher IL-4, lower IL-17 and lower IL-2, respectively). The presence of the most severe MF, psychomotor retardation, was associated with a higher pro-inflammatory response (higher IL-6).

Interpersonal Psychotherapy for Gender Dysphoria in a Transgender Woman

We present a case of a 32-year-old natal male seeking medical follow-up care, due to gender dysphoria (GD) along with other complaints (depressive symptoms, anxiety, and suicidal ideation). The attending team chose interpersonal psychotherapy (IPT), with a focus on role transition in order to help her. The patient presented a favorable trajectory throughout treatment and demonstrated personal growth one year after treatment. To our knowledge, little was found in the literature on the use of IPT in the treatment of those with GD; we also did not find any other publication or case report using IPT exclusively to treat the problems accompanying role transition. Psychotherapy was not intended to change the gender identity of this individual. However, further studies will be required to explore possible benefits of IPT for GD treatment.

The Effects of Individual Psychotherapy in BDNF Levels of Patients With Mental Disorders: A Systematic Review

BACKGROUND

Brain-derived Neurotrophic Factor (BDNF) is considered the main cerebral neurotrophin and is produced in the central neural system and peripherals. Its levels are reduced in patients with several psychiatric disorders, but it is unclear if the response to psychotherapy can alter its concentration.

OBJECTIVE

To carry out a systematic review evaluating the effects of individual psychotherapy in BDNF levels in patients with mental disorders.

METHODS

The databases PubMed, EMBASE, PsycArticles, SciELO, Web of Science, and CENTRAL; the last search was performed on October 2019 for trials evaluating the effects of individual psychotherapy in BDNF levels in adults with mental disorders. PROSPERO registration: CRD42018108144.

RESULTS

Eight of 293 studies were included. A rise in BDNF levels was observed in depressive patients when psychotherapy was combined with medication. Patients with post-traumatic stress disorder (PTSD) who responded to therapy presented a raise in BDNF levels mostly when combined with physical activity. There was a rise in BDNF levels in those who responded to psychotherapy in patients with bulimia, in borderline patients, and in insomniacs.

CONCLUSIONS

The BDNF seems to present variations after psychotherapy especially in patients with bulimia, PTSD, insomnia, and borderline. These subjects also have symptom reduction. Thereby, BDNF could be a supplemental tool to analyze the success to psychotherapy. BDNF levels in patients with major depression after therapy are still controversial and the short follow-up of most studies is a limiting factor.

Longitudinal Investigation of Psychotherapy Outcomes (LIPO): Description of the Study Protocol

Background: Despite extensive research in the field of psychotherapies, few studies have compared the primary psychotherapies of naturalistic design, which represents real-life situations. Objective: The objectives of this study were to evaluate three modalities of evidence-based psychotherapy for clinical, psychosocial, and biological outcomes and to identify the mediators and confounders of this process. Our primary hypothesis is that all psychotherapies will improve clinical and psychosocial outcomes and will increase BDNF levels. Methods: Design: longitudinal, naturalistic. Participants: One hundred twenty-six patients who underwent one of three evidence-based modalities of individual psychotherapy [psychodynamic psychotherapy (PDT), interpersonal psychotherapy (IPT), and cognitive-behavioral psychotherapy (CBT)] were included. Measure: Primary outcomes are divided into three domains of variables: clinical (general psychiatric symptoms), biological (serum BDNF levels), and psychosocial (resilience, quality of life, coping strategies, social support, and quality of life-adjusted years of life). Confounding/mediator variables included clinical (personality traits, type of psychotherapy, number of sessions, concomitant use of pharmacological treatment, history of previous psychotherapeutic treatment, medical and psychiatric comorbidities, and psychiatric diagnosis), psychosocial (psychosocial stressors, therapeutic alliance, and defense mechanism style), and other (religiosity) factors. Procedure: The follow-up period will be baseline and 6 months and 1 year after entering the study. The study will include 42 controls for biological variables only. Sample size calculation considered a significance level of 5% and a power of 80% to detect a difference of 0.22 with a standard deviation of 0.43, assuming losses of 20-30% of patients. The comparison between the modalities of psychotherapy will be by generalized estimating equations (GEE) model, the analysis of mediators by the Hayes method, and confounders by multivariate logistic regression. Discussion: The findings of this study are intended to demonstrate the outcomes of evidence-based psychotherapies for clinical, psychosocial, and biological parameters and to understand the mediators and confounders of this process in a real-life setting for patients with severe mental illness, thus contributing to the establishment of evidence-based public health policies in the field of psychological interventions.

Increased Levels of Brain-Derived Neurotrophic Factor Are Associated With High Intrinsic Religiosity Among Depressed Inpatients

Recognition of the importance of religion and spirituality in psychiatry is increasing, and several studies have shown a predominantly inverse relationship between religiosity and depression. Brain-derived neurotrophic factor (BDNF) is a widely studied brain neurotrophin responsible for synaptic plasticity, dendritic and neuronal fiber growth, and neuronal survival. The objective of the present study was to evaluate BDNF levels across high and low intrinsic religiosity (IR) in depressed inpatients. Serum BDNF levels were evaluated from 101 depressed inpatients at hospital admission and 91 inpatients at discharge. Religiosity was assessed using a validated version of the Duke University Religion Index. High IR patients had significantly higher serum BDNF at discharge than do low IR (52.0 vs. 41.3 ng/mL, P = 0.02), with a Cohen's d effect size difference of 0.56. High IR patients had a statistically significant increase in BDNF levels from admission to discharge (43.6 ± 22.4 vs. 53.8 ± 20.6 ng/mL, -1.950 (paired t-statistic), P = 0.05). The relationship between IR and BDNF levels (F = 6.199, P = 0.00) was controlled for the effects of depressive symptoms ( β = 2.73, P = 0.00) and psychiatric treatments, including selective serotonin reuptake inhibitors (SSRIs) (β = 0.17, P = 0.08), serotonin and norepinephrine reuptake inhibitors (SNRIs) ( β = -0.23, P = 0.02), tricyclic antidepressants (TCAs) ( β = -0.17, P = 0.10), lithium ( β = 0.29, P = 0.00), anticonvulsants ( β = 0.22, P = 0.03), antipsychotics ( β = -0.05, P = 0.61), and electroconvulsive therapy ( β = 0.00, P = 0.98). The current findings suggest a potential pathway to help understand the protective effect of religiosity in depressive disorders.

Lower levels of brain-derived neurotrophic factor are associated with melancholic psychomotor retardation among depressed inpatients

OBJECTIVES

Melancholic depression is a type of depression which is closely related to biological variables than are other types of depression. Its clinical features can be assessed using six items on the Hamilton Depression Rating Scale (HAM-D₆ ). Previous studies have shown, using item response theory, that the symptom depressed mood is the least severe melancholic feature; work and activities, somatic symptoms and psychic anxiety are of moderate severity; and feelings of guilt and psychomotor retardation are the most severe. We aimed to evaluate whether the more severe melancholic signs or symptoms were associated with decreases in brain-derived neurotrophic factor (BDNF) levels.

METHODS

A total of 151 severely depressed inpatients had their BDNF levels analyzed by comparing those who presented with each HAM-D₆ melancholic feature to those for whom the HAM-D₆ feature was absent, using multiple linear regressions. The levels of BDNF of patients who presented with each melancholic feature were also compared with those of 100 healthy controls.

RESULTS

Depressed patients' median BDNF level was 44.06 ng/mL (interquartile range [IQR]: 33.99-62.4 ng/mL), and controls' median BDNF level was 65.22 ng/mL (IQR: 49.87-76.08 ng/mL) (P < .001). The presence of depressed mood, work and activities, somatic symptoms, psychic anxiety, and guilty feelings was not associated with BDNF levels. However, the presence of psychomotor retardation was associated with reduced BDNF (median reduction -10.07 ng/mL; 95% confidence interval [CI]: -19.43 to -0.71; P = .03).

CONCLUSIONS

To the best of our knowledge, this study is the first to associate BDNF levels with melancholic features in a sample of severely depressed inpatients. The main finding of this study was that severely depressed inpatients who presented the most severe melancholic feature, psychomotor retardation, had significantly reduced BDNF levels in the blood.

Readmission in psychiatry inpatients within a year of discharge: The role of symptoms at discharge and post-discharge care in a Brazilian sample

INTRODUCTION

Readmission into inpatient psychiatric beds is a useful outcome for patients, care providers, and policymakers. This study aims to investigate the role of level of symptoms at discharge and type of post-discharge care in determining readmissions after a year before a psychiatric admission.

METHODS

We performed a prospective and observational study in a general hospital psychiatric facility. Patients were assessed at admission, discharge, and one year after discharge. We used a multivariable logistic regression to determine predictors of readmission.

RESULTS

In total, 488 patients were included at admission, and 401 (82,17%) were accessed in the follow-up period. Psychiatric readmissions occurred in 29.17% of the followed patients. The number of previous admissions represents a 38% higher chance of being readmitted (OR 1.38; CI 1.16-1.60). For patients admitted in a depressive episode, not being in remission at discharge increases 140% the chance to be readmitted (OR 2.40; CI 1.14-5.07) as well as the follow-up at primary (OR 5.27; CI 1.06-26.15). For those with Schizophrenia and related disorders, higher scores in BPRS at discharge increases the chance to be readmitted (OR 1.28, CI 1.11-1.48).

CONCLUSION

Level of symptoms at discharge was related to higher chance to be readmitted in patients admitted in a depressive episode and those with schizophrenia and related disorders. Findings of the type of care raise the need for further investigation. Also, this finding confirms the importance of the history of previous admissions in predicting future admissions.

Childhood trauma and suicide attempt: A meta-analysis of longitudinal studies from the last decade

Childhood trauma (CT) is a modifiable risk factor for lifetime suicide attempts (SA). However, the extent to which each type of CT increases SA risk is unclear. This study aimed to conduct a meta-analysis of longitudinal studies published in the last 10 years about the relationship between CT and lifetime SA risk. The PUBMED, PsycINFO, ISI, and EMBASE databases were searched for cohort studies that reported AS during follow-up and included an assessment of CT. A meta-analysis was conducted to identify potential effects of each type of CT on SA. Seven unique studies were included for review. Sexual (n=6, OR=3.73, 95%CI 2.94-4.75, p<0.001), physical (n=6, OR=4.11, 95%CI 2.30-7.33, p<0.001), and emotional abuse (n=3, OR=3.98, 95%CI 2.89-5.64, p<0.001), as well as physical neglect (n=2, OR=3.42, 95%CI 2.09-5.59, p<0.001), were associated with SA. Emotional neglect and a broken home were not significantly associated with further SA. The modes of CT that most contribute to SA in later life are physical, emotional, and sexual abuse and physical neglect, in descending order.

The association of electroconvulsive therapy to pharmacological treatment and its influence on cytokines

INTRODUCTION

A growing body of evidence shows that disturbances in the immune system are involved in the pathogenesis of depression. Although the immune-modulating effects of antidepressants have been described, few studies have addressed the functioning of the immune system in relation to electroconvulsive therapy (ECT). This study aims to investigate if the addition of ECT to pharmacotherapy is associated with changes in cytokine levels.

METHODS

Adult inpatients were invited to participate in this study on admission to a psychiatric unit. Those with a diagnosis of depression by Mini-International Neuropsychiatric Interview were included. At treatment discharge, patients were retrospectively divided into those who used combined ECT and pharmacotherapy (31 subjects) and those who used only pharmacotherapy (68 subjects). Pro-inflammatory cytokines IL-2, IL-6, TNF-α, IFN-γ, and IL-17, and anti-inflammatory IL-4 and Il-10, were measured in blood samples collected at admission and discharge. A generalized estimating equation model and the post hoc Bonferroni test were performed for statistical analysis.

RESULTS

The combination of ECT with pharmacotherapy was associated with a decrease of IL-6 and an increase of TNF-α. Depressive inpatients, as a whole group, had a decrease of IL-6 and an increase of IFN-γ. No significant results were found for IL-2, IL-4, Il-10 and IL-17.

CONCLUSION

This study is clinically relevant because we highlight that, in agreement with the previous literature, IL-6 appears to be a useful marker in depression, and we show for the first time that its reduction is closely related to the use of ECT.

The Major Depressive Disorder Hierarchy: Rasch Analysis of 6 items of the Hamilton Depression Scale Covering the Continuum of Depressive Syndrome

OBJECTIVES

Melancholic features of depression (MFD) seem to be a unidimensional group of signs and symptoms. However, little importance has been given to the evaluation of what features are related to a more severe disorder. That is, what are the MFD that appear only in the most depressed patients. We aim to demonstrate how each MFD is related to the severity of the major depressive disorder.

METHODS

We evaluated both the Hamilton depression rating scale (HDRS-17) and its 6-item melancholic subscale (HAM-D6) in 291 depressed inpatients using Rasch analysis, which computes the severity of each MFD. Overall measures of model fit were mean (±SD) of items and persons residual = 0 (±1); low χ2 value; p>0.01.

RESULTS

For the HDRS-17 model fit, mean (±SD) of item residuals = 0.35 (±1.4); mean (±SD) of person residuals = -0.15 (±1.09); χ2 = 309.74; p<0.00001. For the HAM-D6 model fit, mean (±SD) of item residuals = 0.5 (±0.86); mean (±SD) of person residuals = 0.15 (±0.91); χ2 = 56.13; p = 0.196. MFD ordered by crescent severity were depressed mood, work and activities, somatic symptoms, psychic anxiety, guilt feelings, and psychomotor retardation.

CONCLUSIONS

Depressed mood is less severe, while guilt feelings and psychomotor retardation are more severe MFD in a psychiatric hospitalization. Understanding depression as a continuum of symptoms can improve the understanding of the disorder and may improve its perspective of treatment.

Association between Spirituality and Adherence to Management in Outpatients with Heart Failure

Background

Spirituality may influence how patients cope with their illness.

Objectives

We assessed whether spirituality may influence adherence to management of outpatients with heart failure.

Methods

Cross sectional study enrolling consecutive ambulatory heart failure patients in whom adherence to multidisciplinary treatment was evaluated. Patients were assessed for quality of life, depression, religiosity and spirituality utilizing validated questionnaires. Correlations between adherence and psychosocial variables of interest were obtained. Logistic regression models explored independent predictors of adherence.

Results

One hundred and thirty patients (age 60 ± 13 years; 67% male) were interviewed. Adequate adherence score was observed in 38.5% of the patients. Neither depression nor religiosity was correlated to adherence, when assessed separately. Interestingly, spirituality, when assessed by both total score sum (r = 0.26; p = 0.003) and by all specific domains, was positively correlated to adherence. Finally, the combination of spirituality, religiosity and personal beliefs was an independent predictor of adherence when adjusted for demographics, clinical characteristics and psychosocial instruments.

Conclusion

Spirituality, religiosity and personal beliefs were the only variables consistently associated with compliance to medication in a cohort of outpatients with heart failure. Our data suggest that adequately addressing these aspects on patient’s care may lead to an improvement in adherence patterns in the complex heart failure management.

Combining ECT with pharmacological treatment of depressed inpatients in a naturalistic study is not associated with serum BDNF level increase

BACKGROUND

BDNF blood levels are reduced in MDD. They can be increased with pharmacologic treatment and ECT, but it is not clear whether the combination of treatments promotes an additional increase. The present study aims to evaluate whether combined treatment promotes an increase in BDNF, restoring the level to that of non-depressed controls.

METHODS

Ninety-nine adult inpatients were invited to participate in this naturalistic prospective cohort study between May 2011 and April 2013. Diagnosis was made by MINI, and the symptoms were evaluated at admission and at discharge by HDRS-17. Those inpatients with a diagnosis of depression were included and divided into two groups: those who underwent combined ECT and medication (31 subjects) and those who used only pharmacotherapy (68 subjects). Serum BDNF was measured in blood samples collected at admission and discharge. One hundred healthy blood donors without any psychiatric diagnosis were included as a control group.

RESULTS

There were no significant differences in serum BDNF levels between the combined and pharmacological groups at admission and at discharge, and no significant variation in BDNF occurred in any group during the treatment. There were no interactions between time and treatment groups nor significant time effects or treatment group effects for BDNF in the Generalized Estimating Equation Model (GEE). The control group had significantly higher serum BDNF levels in comparison with each of the treatment groups at admission and discharge (p = 0.00).

CONCLUSION

Combination of ECT with pharmacological treatment did not result in increased serum BDNF levels and did not restore levels to that of controls.

Intrinsic religiosity, resilience, quality of life, and suicide risk in depressed inpatients

BACKGROUND

Religiosity is inversely related to depression and is directly associated with positive psychological outcomes. Nonetheless, there is no consensus on whether or how religiosity could impact and protect against depression. The present study evaluated the association between intrinsic religiosity and resilient psychological characteristics in depressed inpatients.

METHODS

A sample of 143 depressed patients was prospectively evaluated in an inpatient psychiatric treatment in South Brazil. High Intrinsic Religiosity (HIR) and Low Intrinsic Religiosity (LIR) patients were compared across socio-demographic information, clinical measures, religiosity, resilience and quality of life. A linear regression model was used to evaluate the association between intrinsic religiosity and resilience, and the Cohen d test was utilized to assess effect sizes.

RESULTS

At admission, HIR patients showed higher HAM-D (p=0.05), BPRS (p=0.02), GAF (p=0.02), and CGI (p=0.03) scores, lower educational levels (p=0.04), higher social support (p=0.05), and fewer previous suicide attempts (p=0.05). At discharge, HIR patients showed higher quality of life (p=0.001) and higher resilience (p=0.000), with a large effect size difference between groups (1.02). Based on a linear regression model (adjusted r=0.19, p=0.000), intrinsic religiosity was associated with resilience, controlling for covariates.

CONCLUSION

In a sample of depressed inpatients, intrinsic religiosity was found to be associated with resilience, quality of life, and fewer previous suicide attempts. These findings support the relevance of religiosity assessments in mental health practice and support the hypothesis that resilient psychological characteristics may mediate the positive effects of intrinsic religiosity in depression.

Quality of life in caregivers of children and adolescents with Osteogenesis Imperfecta

Background

Osteogenesis imperfecta (OI) is a group of genetic disorders of collagen biosynthesis, characterized by low bone density leading to fractures. Most patients exhibit functional impairment and require the aid of a caregiver. The aim of this study is to assess the quality of life (QoL) of caregivers of patients with OI.

Methods

In this cross-sectional study, a convenience sampling strategy was used to enroll adult caregivers of children and adolescents with OI who attended a referral center in southern Brazil. The WHOQOL-BREF instrument was used to assess QoL.

Results

Twenty-four caregivers of 27 patients (10 with type I, 4 with type III, and 13 with type IV OI) were included in the study. Eighteen caregivers were the patients’ mothers, two had OI, and 22 cared for only one patient. Mean WHOQOL-BREF scores were 14.59 for the physical health domain, 13.80 for the psychological domain, 15.19 for the social relationships domain, and 12.87 for the environmental domain; the mean total QoL score was 14.16. QoL scores did not differ significantly according to patients’ OI type or number of fractures. Economic status was not correlated significantly with QoL scores.

Conclusions

QoL appears to be impaired in caregivers of patients with OI. Additional studies are required to confirm these findings and to ascertain which factors account for this phenomenon.

Evaluating psychiatric case-control studies using the STROBE (STrengthening the Reporting of OBservational Studies in Epidemiology) statement

CONTEXT AND OBJECTIVE

Case-control studies are important in developing clinical and public health knowledge. The STROBE statement (STrengthening the Reporting of OBservational Studies in Epidemiology) was developed to establish a checklist of items that should be included in articles reporting observational studies. Our aim was to analyze whether the psychiatric case-control articles published in Brazilian journals with CAPES Qualis rating B1/B2 in 2009 conformed with the STROBE statement.

DESIGN AND SETTING

Descriptive study on psychiatric papers published in Brazilian journals, within the Postgraduate Medical Program on Psychiatry, at Universidade Federal do Rio Grande do Sul.

METHODS

All psychiatric case-control studies from Brazilian Qualis B1/B2 journals of psychiatry, neurology and public health in 2009 were analyzed. The four most specific items of the STROBE statement were used to evaluate whether these studies fitted within the case-control parameters: 1) selection of cases and controls; 2) controlling for bias; 3) statistical analysis; and 4) presentation of results.

RESULTS

Sixteen case-control studies were identified, of which eleven (68.75%) were in psychiatry-focused journals. From analysis using the STROBE statement, all of the articles conformed with item 1; two (12.5%) completely conformed with item 2; none completely conformed with item 3; and only three (18.8%) conformed with item 4.

CONCLUSION

The case-control studies analyzed here did not completely conform with the four STROBE statement items for case-control design. In view of the inadequate methodology of the published studies, these findings justify focusing on research and methodology and expanding the investigations on adherence of studies to their designs.

An introduction to Rasch analysis for Psychiatric practice and research

This article aims to present the main characteristics of Rasch analysis in the context of patient reported outcomes in Psychiatry. We present an overview of the main features of the Rasch analysis, using as an example the latent variable of depressive symptoms, with illustrations using the Beck Depression Inventory. We will show that with fitting data to the Rasch model, we can confirm the structural validity of the scale, including key attributes such as invariance, local dependency and unidimensionality. We also illustrate how the approach can inform on the meaning of the numbers attributed to scales, the amount of the latent traits that such numbers represent, and the consequent adequacy of statistical operations used to analyse them. We would argue that fitting data to the Rasch model has become the measurement standard for patient reported outcomes in general and, as a consequence will facilitate a quality improvement of outcome instruments in psychiatry. Recent advances in measurement technologies built upon the calibration of items derived from Rasch analysis in the form of computerized adaptive tests (CAT) open up further opportunities for reducing the burden of testing, and/or expanding the range of information that can be collected during a single session.

Pharmacological treatment of bipolar depression: qualitative systematic review of double-blind randomized clinical trials

Randomized clinical trial (RCT) is the best study design for treatment-related issues, yet these studies may present a number of biases and limitations. The objective of this study is to carry out a qualitative analysis of RCT methodology in the treatment of bipolar depression (BD). A systematic review covering the last 20 years was performed on PubMed selecting double-blind RCTs for BD. The identification items of the articles, their design, methodology, outcome and grant-related issues were all analyzed. Thirty articles were included, all of which had been published in journals with an impact factor >3. While almost half studies (46.7%) used less than 50 patients as a sample, 70% did not describe or did not perform sample size calculation. The Last Observation Carried Forward (LOCF) method was used in 2/3 of the articles and 53.4% of the studies had high sample losses (>20%). Almost half the items were sponsored by the pharmaceutical industry and 33.3% were sponsored by institutions or research foundations. Articles on the pharmacological treatment of BD have several limitations which hinder the extrapolation of the data to clinical practice. Methodological errors and biases are common and statistical simplifications compromise the consistency of the findings.

The EUROHIS-QOL 8-item index: comparative psychometric properties to its parent WHOQOL-BREF

OBJECTIVES

To test the psychometric properties of the EUROHIS-QOL 8-item index, a shortened version of the World Health Organization Quality of Life Instrument-Abbreviated Version (WHOQOL-BREF).

METHODS

The sample consisted of 2359 subjects identified from primary care settings, with 1193 having a confirmed diagnosis of depression. Data came from six countries (Australia, Brazil, Israel, Russia, Spain, and the United States) involved in a large international study, the Longitudinal Investigation of Depression Outcomes. The structure of the EUROHIS-QOL 8-item index follows that of the WHOQOL-BREF assessment. Internal consistency was measured by using Cronbach's alpha. Convergent validity was assessed by using correlations with different measures for mental health (Symptom Checklist 90), physical health (self-evaluation), and quality of life (WHOQOL-BREF and short form 36 health survey). Discriminant group validity was assessed between diagnosed depressed and nondepressed patients. Differential item functioning and unidimensionality were analyzed by using Rasch analysis. Factor structure was assessed with structural equation modeling analyses.

RESULTS

Internal consistency was acceptable (ranged between 0.72 and 0.81 across countries), and the index discriminated well between depression (t = 6.31-20.33; P < 0.001) across all countries. Correlations between the EUROHIS-QOL 8-item index and different measures--Symptom Checklist 90 (r = -0.42), physical health (r = -0.42), WHOQOL-BREF domains (r = 0.61-0.77), and short form 36 health survey (r = 0.58)--were all significant (P < 0.001). The index is unidimensional with desired item fit statistics. Two items ("daily living activities" and "enough money to meet your needs") had residuals exceeding 4. Differential item functioning was observed with general quality of life, general health, relationships, and home items for age. A common one-factor structure with acceptable fit was identified in three out of six countries (comparative fit index = 0.85, root mean square error of approximation = 0.11).

CONCLUSIONS

The EUROHIS-QOL 8-item index showed acceptable cross-cultural performance and a satisfactory discriminant validity and would be a useful measure to include in studies to assess treatment effectiveness.

Quality of life of brazilian patients with Gaucher disease and fabry disease

OBJECTIVE

To evaluate QoL in a sample of Brazilian patients with Gaucher (GD) and Fabry (FD) disease using the SF-36 survey.

METHOD

Observational cross-sectional study. The SF-36 survey was administered to cognitively able patients 12 years or older, who were seen in the Medical Genetics Service of Hospital de Clínicas de Porto Alegre, Brazil.

RESULTS

Thirty-five patients were included in the study (GD = 21, FD = 14), mean age was 29.8 ± 14.2 years and 29 (82.9%) were receiving ERT. Patients with GD receiving ERT had better scores in the general health (p = 0.046) domain of the SF-36 than patients with FD receiving ERT. Comparison of patients with GD naive to ERT and those receiving ERT revealed differences only in the bodily pain domain (p = 0.036). The Zimran score showed a moderate negative correlation with the following domains of the SF-36: physical functioning (p = 0.035), role-physical (p = 0.036), general health (p = 0.023) and role emotional (p = 0.021).

DISCUSSION AND CONCLUSION

Although limited because of the small number of patients included, findings suggest that patients with GD receiving ERT have a better QoL than patients with FD or with GD not receiving ERT. Imiglucerase has a beneficial effect against pain for patients with GD. Further studies should be conducted to confirm our findings.

Field-test validation of the brazilian version of the Paediatric Asthma Quality of Life Questionnaire

OBJECTIVE

To assess the psychometric properties of the official Brazilian Portuguese-language version of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) in a representative group of Brazilian children and adolescents with asthma.

METHODS

A total of 125 individuals with asthma, aged 8-17 years and being monitored at a pediatric pulmonology outpatient clinic in the city of Porto Alegre, Brazil, completed the PAQLQ. Validity was assessed by means of convergent validity (correlation between PAQLQ domains and those of the Pediatric Quality of Life Inventory (PedsQL) 4.0. Reliability was assessed by determining internal consistency (Cronbach's alpha coefficient), reproducibility (intraclass correlation coefficient), sensitivity to change (effect size), and discriminatory power (floor/ceiling effects).

RESULTS

The mean age was 11 years, and 75 (60%) of the participants were male. The mean PAQLQ total score was 5.1, with floor/ceiling effects < 10%. Correlations between PAQLQ domains and the PedsQL 4.0 domains were acceptable (r = 0.37-0.40). The Cronbach's alpha coefficient for the total score was 0.93, ranging from 0.72 to 0.88 for the domains. The overall effect size was 0.60 (range: 0.45-0.60), whereas the overall intraclass correlation coefficient was 0.80 (range: 0.66-0.79).

CONCLUSIONS

The official Brazilian Portuguese-language version of the PAQLQ showed good psychometric performance, confirming its cultural adequacy for use in Brazil.

Brazilian validation of the Quality of Life Instrument/spirituality, religion and personal beliefs

OBJECTIVE

To analyze the psychometric properties of the World Health Organization's Quality of Life Instrument--Spirituality, Religion and Personal Beliefs module (WHOQOL-SRPB).

METHODS

The WHOQOL-SRPB, the Brief Spiritual/Religious Coping Scale (Brief-SRCOPE Scale), the WHOQOL-BREF and the Beck Depression Inventory (BDI) were consecutively applied in a convenience sample of 404 patients and workers of a university hospital and workers of a university, in the city of Porto Alegre, Southern Brazil, between 2006 and 2009. The sample was stratified by sex, age, health status and religion/belief. The retest of the two first instruments was conducted with 54 participants. Exploratory factorial analyses of the WHOQOL-SRPB with the method of main components were performed, without limiting the number of factors, and requiring eight factors concomitantly with the WHOQOL-BREF items.

RESULTS

The Brazilian Portuguese version of the WHOQOL-SRPB (General SRPB-Domain) showed construct validity, with a discriminatory validity between believers and non-believers (t = 7.40; p = 0.0001); concurrent criterion-related validity, distinguishing depressed individuals from non-depressed ones (t = 5.03; p = 0.0001); convergent validity with the WHOQOL-BREF (physical r = 0.18; psychological r = 0.46; social r = 0.35; environmental r = 0.29; global r = 0.23; p = 0.0001) and with the SRPB-Domain of the WHOQOL-100 (r = 0.78; p = 0.0001); and convergent/discriminatory validity with the brief SRCOPE Scale (with positive SRCOPE r = 0.64; p = 0.0001/negative SRCOPE r = -0.03; p = 0.554). Excellent test-retest reliability (t = 0.74; p = 0.463) and internal consistency (α = 0.96; intrafactorial correlation 0.87 > r > 0.60; p = 0.0001) were observed. The exploratory factorial analyses performed corroborated the eight-factor structure of the WHOQOL-SRPB multicenter study.

CONCLUSIONS

The Brazilian Portuguese version of the WHOQOL-SRPB showed good psychometric qualities and use valid and reliable in Brazil. It is suggested that new studies be conducted with specific populations, such as different religions, cultural groups and/or diseases.

Evaluation of quality of life in adults with chronic health conditions: the role of depressive symptoms

OBJECTIVE: The negative impact of depressive symptoms on quality of life has been the focus of increasing attention, yet this relation remains unstudied in samples from developing countries. The objective of this study was to determine whether the occurrence of depressive symptoms is associated with impaired quality of life and whether this association remains significant after adjustment for some variables. METHOD: A convenience sample was selected and the measures used were the WHOQOL-100, to assess quality of life, the Beck Depression Inventory, to screen for depressive symptoms, and the Economic Classification Criterion - Brazil, to evaluate socioeconomic status. RESULTS: One hundred nineteen healthy adults (community) and 122 adult patients (tertiary hospital) from Brazil were assessed. Depressive symptoms were negatively correlated with all the domains of quality of life, even after statistical control for age, socioeconomic status, and presence of chronic health conditions. Socioeconomic status was positively correlated with the social relationships and environmental domains of quality of life. CONCLUSION: Our findings indicate that depressive symptoms and socioeconomic status are important elements affecting the relationship between chronic health conditions and quality of life in Brazil.

Is there a measurement overlap between depressive symptoms and quality of life?

BACKGROUND

Previous studies found that depression is associated with a broad impairment in quality of life (QOL). This finding might be associated to a measurement overlap.

METHODS

The objective of this study was to verify whether the items of the World Health Organization Quality of Life Instrument-Abbreviated version (WHOQOL-BREF), a measure of generic QOL, are invariant among patients having a current major depressive episode who come from primary care services. We investigated data from primary care services from the 6 countries (Australia, Brazil, Israel, Russia, Spain, and the United States) involved in the baseline sample of the Longitudinal Investigation of Depression Outcomes. The Rasch model was used to analyze items exhibiting differential item functioning (DIF) as a way of assessing invariance in relation to a depression factor defined by the diagnosis of depression using the Composite International Diagnostic Interview. In addition, the Center for Epidemiological Studies-Depression Scale (CES-D) score was correlated with the item and domain scores of the WHOQOL-BREF using the Pearson coefficient.

RESULTS

The sample consisted of 2359 subjects, of which 1193 had a confirmed diagnosis of a current major depressive episode. Of the 26 items of the WHOQOL-BREF, 11 showed DIF due to the depression factor, and the physical domain presented more items displaying DIF. All Pearson coefficients between the WHOQOL-BREF item and domain scores and the CES-D score were weak and moderate (r = -0.13 to r = 0.43).

CONCLUSIONS

Our findings indicate that most WHOQOL-BREF items do not exhibit DIF for a current major depressive episode and the variance associated with depression in this generic QOL measure is restricted to some facets of this construct. Thus, we recommend this restricted adjustment for depression in future analyses of this measure. Furthermore, our study indicates that researchers must measure QOL regardless of depression severity.

Validity of the Brazilian version of WHOQOL-BREF in depressed patients using Rasch modelling

OBJECTIVE: To assess the validity of the Brazilian version of the World Health Organization Quality of Life Instrument - Abbreviated version (WHOQOL-BREF) in adults with major depression, using Rasch modelling. METHODS: Study analyzing data from the baseline sample of the Longitudinal Investigation of Depression Outcomes in Brazil, including a total of 208 patients with major depression recruited in a primary care service in Porto Alegre (Southern Brazil), in 1999. The Center for Epidemiological Studies Depression Scale was used to assess intensity of depression; the WHOQOL-BREF to assess generic quality of life; and the Composite International Diagnostic Interview version 2.1 for the diagnosis of depression. RESULTS: In the Rasch analysis, the four domains of WHOQOL-BREF showed appropriate fit to this model. Some items needed adjustments: four items were rescored (pain, finances, services, and transport); two items (work and activity) were identified as having dependency of responses, and one item was deleted (sleep) due to multidimensionality. CONCLUSIONS: The validation of the WHOQOL-BREF Brazilian version using Rasch analysis complements previous validation studies, evidencing the robustness of this instrument as a generic cross-cultural quality of life measure.

The influence of somatic symptoms on the performance of elders in the Beck Depression Inventory (BDI)

BACKGROUND: The Beck Depression Inventory (BDI) has been widely used to assess the prevalence of depressive symptomatology in clinical and non-clinical samples. On elders, however, the Beck Depression Inventory total score can be influenced by the increased scores on somatic and performance subscale due to the impact of ageing process itself and clinical diseases. PURPOSE: To verify if there are differences between answers of adults and elders for the BDI Somatic and Performance subscale. METHODS: Five hundred and fifty six subjects were interviewed. Two hundred and seventeen were adults (between 18 and 59 years old) and 339 were elders (> 60 years). Adults and elders with terminal diseases or dementia were excluded. The convenience sampling method was used. RESULTS: Elders answered significantly with higher scores in the Somatic and Performance subscale compared to adults (p < 0.001). Female gender and educational level were also associated to higher scores in the Somatic subscale. No differences between both age groups were found in the Cognitive-Affective subscale (p = 0.332). CONCLUSIONS: Positive answers in the BDI Somatic and Performance subscale must be carefully assessed among elder subjects. The age factor, either by aging or due to several diseases, can bring signs that are not necessarily symptoms of major depression. Further studies are suggested.

[Development of WHOQOL spirituality, religiousness and personal beliefs module]

OBJECTIVES

To describe the development of the "spirituality, religiousness, and personal beliefs" for the WHOQOL-SRBP instrument, and to report the main findings of research conducted with focus groups composed of subjects representative of the most common religious practices, patients, and healthcare professionals.

METHODS

The several stages of the development of the WHOQOL-SRBP instrument are described: literature review, focus groups, elaboration of national questions, elaboration of consensual items, pilot-study development, pilot-study application, question performance analysis, development of the definitive instrument, and field testing. The focus group stage was conducted in Porto Alegre, Southern Brazil, and included 15 groups (n=142). These included separate groups for healthcare professionals, acute, chronic, and terminal patients, religious groups (Catholics, Evangelicals, Afro-Brazilians, and Spiritualists), and atheists. Each group discussed facets suggested by a group of "experts", as well as any further dimensions spontaneously raised by group participants.

RESULTS AND CONCLUSIONS

The focus group technique proved itself adequate for the collection of different opinions from the participants, allowing for the testing of the hypotheses proposed by the researchers, redirecting and/or broadening previously established concepts. In addition, it highlighted the importance of the discussion of the spiritual dimension for patient's lives.