Dr Sadgun Bhandari - A PRELIMNARY REVIEW. Dr. Sadgun Bhandari is a General Psychiatrist Consultant and an expert at the management of Serious Mental Illness especially Schizophrenia and Bipolar Affective Disorder.
Placebo effect in clinical research is a fascinating and widely researched phenomenon in biomedical research and medicine in general. Presentation is an overview of origins and impact of placebo effect in development of new medicines.
Placebo effect in clinical research is a fascinating and widely researched phenomenon in biomedical research and medicine in general. Presentation is an overview of origins and impact of placebo effect in development of new medicines.
Cure, how placebo works, placebo, placebo effect, What is the placebo effect, Mechanism of the placebo effect, How does the placebo effect works, How are placebos used
Kick Start Your Health: Reduce anxiety, depression, start sleeping and feelin...Insights To Health
Have you been feeling run down, stressed, depressed and just plain ‘blah’? Have you been struggling with headaches or lack of sleep? Are you feeling frustrated because you’re not getting the results you would like with your health? You’re not alone.
I’ve created a new training series that is going to show you why you’re struggling and - better yet - it will show you what you can do about it.
Our philosophy here at Insights To Health is to treat the whole person, not random symptoms. In order to do that YOU (our patient) need to understand how your health works, what YOU can do about it, and when to get the help you need.
I’m going to reveal:
▪ Why the traditional healthcare route - symptom-prescription cycle - doesn’t work. In fact, it can make things worse!
▪ How you can take control of your own healthcare and save tons of money at the same time
▪ Best of all, how you can finally get the rest and relief you need and start feeling your best now
▪ I’m going to let you in on something new that’s coming to Insights To Health that will give you the tools to take charge of your own, and your family’s, health for good
Psilocybin Therapy May Be 4x More Effective in Treating DepressionEvergreen Buzz
Psilocybin is great for depression, read this https://cannabis.net/blog/medical/psilocybinassisted-therapy-may-be-4x-more-effective-in-treating-major-depression-in-patients
Basic introduction to clinical trials and the placebo effect. Definitions, examples and cartoons illustrating the subject. Ends with short info on informed consent.
KEYNOTE presentation (June 2015), ESCAP Expert Paper (July 2015), TV interview and abstract by professor Beate Herpertz-Dahlmann (Aachen University) on new developments in the diagnostics and treatment of adolescent eating disorders
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
Treating Insomnia in Depression Insomnia Related Factors Pred.docxturveycharlyn
Treating Insomnia in Depression: Insomnia Related Factors Predict
Long-Term Depression Trajectories
Bei Bei
Monash University and Royal Women’s Hospital, University of
Melbourne
Lauren D. Asarnow
Stanford University
Andrew Krystal
University of California, San Francisco
Jack D. Edinger
National Jewish Health, Denver, Colorado, and Duke University
Medical Center
Daniel J. Buysse
University of Pittsburgh
Rachel Manber
Stanford University
Objective: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has
been associated with poorer outcomes for both conditions. However, individual differences in depressive
symptom trajectories during and after treatment are poorly understood in comorbid insomnia and
depression. This study explored the heterogeneity in long-term depression change trajectories, and
examined their correlates, particularly insomnia-related characteristics. Method: Participants were 148
adults (age M � SD � 46.6 � 12.6, 73.0% female) with insomnia and MDD who received antidepressant
pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or
control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were
assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs
about sleep were also assessed. Results: Growth mixture modeling revealed three trajectories: (a)
Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value � .001)
and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom
reduction during treatment (p values � .001) and low depression severity at posttreatment, but increased
severity over follow-up (p value � .001). (c) Optimal-Responders (13.5%) achieved most gains during
early treatment (p value � .001), continued to improve (p value � .01) and maintained minimal
depression during follow-ups. The classes did not differ significantly on baseline measures or treatment
received, but differed on insomnia-related measures after treatment began (p values � .05): Optimal-
Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about
sleep. Conclusions: Three depression symptom trajectories were observed among patients with comorbid
insomnia and MDD. These trajectories were associated with insomnia-related constructs after commenc-
ing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes.
What is the public health significance of this article?
This study identified three distinct depression trajectories in patients with comorbid major depression
and insomnia disorders during treatment and 2-year follow-up. Those with the largest and most
sustained improvements in depression consistently scored the lowest on postbaseline insomnia and
insomnia-related cognitions. Early changes in insomnia symptoms and insomnia-related character ...
Cure, how placebo works, placebo, placebo effect, What is the placebo effect, Mechanism of the placebo effect, How does the placebo effect works, How are placebos used
Kick Start Your Health: Reduce anxiety, depression, start sleeping and feelin...Insights To Health
Have you been feeling run down, stressed, depressed and just plain ‘blah’? Have you been struggling with headaches or lack of sleep? Are you feeling frustrated because you’re not getting the results you would like with your health? You’re not alone.
I’ve created a new training series that is going to show you why you’re struggling and - better yet - it will show you what you can do about it.
Our philosophy here at Insights To Health is to treat the whole person, not random symptoms. In order to do that YOU (our patient) need to understand how your health works, what YOU can do about it, and when to get the help you need.
I’m going to reveal:
▪ Why the traditional healthcare route - symptom-prescription cycle - doesn’t work. In fact, it can make things worse!
▪ How you can take control of your own healthcare and save tons of money at the same time
▪ Best of all, how you can finally get the rest and relief you need and start feeling your best now
▪ I’m going to let you in on something new that’s coming to Insights To Health that will give you the tools to take charge of your own, and your family’s, health for good
Psilocybin Therapy May Be 4x More Effective in Treating DepressionEvergreen Buzz
Psilocybin is great for depression, read this https://cannabis.net/blog/medical/psilocybinassisted-therapy-may-be-4x-more-effective-in-treating-major-depression-in-patients
Basic introduction to clinical trials and the placebo effect. Definitions, examples and cartoons illustrating the subject. Ends with short info on informed consent.
KEYNOTE presentation (June 2015), ESCAP Expert Paper (July 2015), TV interview and abstract by professor Beate Herpertz-Dahlmann (Aachen University) on new developments in the diagnostics and treatment of adolescent eating disorders
Case # 29- The depressed man who thought he was out of options. .docxannandleola
Case # 29- The depressed man who thought he was out of options.
Depression has become a common mental disorder in our elderly population. This has caused a global concern for occur, geriatric patients, as depression often results in a significant burden for families as well as communities. Elderly people who suffer from depression may have an inferior baseline and record for medical assessments than those individuals without depression. Despite consistent evidence of the effectiveness of antidepressants for many with depression,
3
particularly those with more severe depression, remission rates are disappointingly low. An AHRQ-sponsored report found that only 46% of patients experienced remission from depression during 6 to 12 weeks of treatment with second-generation antidepressants. One major reason for this issue is non-adherence to medications and treatment plans. Studies have shown that patients' age, race and ethnicity are consistently associated with predictions of outcomes. (Rossom et al., 2016).
This case study involves a 69-year old man whose chief complaint is unremitting, chronic depression. After several years of medications and treatments, he feels hopeless for a recovery from his chronic depression. This assignments seeks to explore his family and social support systems, diagnostic testing, differential diagnosis and pharmacologic treatment options for this patient.
Questions for the client
How have you been sleeping lately?
How many times in the last week have you had feelings of hopelessness?
Are you having thoughts of harming yourself? Do you have a plan?
These questions are an important yet simple place to start when treating patients. Sleep disturbances plague much of the world's population and have shown to be a major indicator for mental health issues. Changes in sleep neurophysiology are often observed in depressive patients, and impaired sleep is, in many cases, the chief complaint of depression (Armitage, 2007). Depressed patients with sleep disturbance are likely to present more severe symptoms and difficulties in treatment. In addition, persistent insomnia is the most common residual symptom in depressed patients and is considered a vital predictor of depression relapse and may contribute to unpleasant clinical outcomes (Hinkelmann et al., 20120. Questions involving feelings of hopelessness and suicidal ideations with or without a plan relate to issues of patient safety. Across psychiatric disorders, hopelessness is associated with suicidal ideation and behavior. A meta-analysis of 166 longitudinal studies (sample size not reported) found that hopelessness was associated with an increased risk of ideation (Ribeiro, Huang, Fox, & Franklin, 2018).
Family and social support system
Family and social support systems are imperative for any patient in recovery. If the patient is agreeable to discussions with family members, then a discussion with his wife would be helpful. Researc.
Treating Insomnia in Depression Insomnia Related Factors Pred.docxturveycharlyn
Treating Insomnia in Depression: Insomnia Related Factors Predict
Long-Term Depression Trajectories
Bei Bei
Monash University and Royal Women’s Hospital, University of
Melbourne
Lauren D. Asarnow
Stanford University
Andrew Krystal
University of California, San Francisco
Jack D. Edinger
National Jewish Health, Denver, Colorado, and Duke University
Medical Center
Daniel J. Buysse
University of Pittsburgh
Rachel Manber
Stanford University
Objective: Insomnia and major depressive disorders (MDD) often co-occur, and such comorbidity has
been associated with poorer outcomes for both conditions. However, individual differences in depressive
symptom trajectories during and after treatment are poorly understood in comorbid insomnia and
depression. This study explored the heterogeneity in long-term depression change trajectories, and
examined their correlates, particularly insomnia-related characteristics. Method: Participants were 148
adults (age M � SD � 46.6 � 12.6, 73.0% female) with insomnia and MDD who received antidepressant
pharmacotherapy, and were randomized to 7-session Cognitive Behavioral Therapy for Insomnia or
control conditions over 16 weeks with 2-year follow-ups. Depression and insomnia severity were
assessed at baseline, biweekly during treatment, and every 4 months thereafter. Sleep effort and beliefs
about sleep were also assessed. Results: Growth mixture modeling revealed three trajectories: (a)
Partial-Responders (68.9%) had moderate symptom reduction during early treatment (p value � .001)
and maintained mild depression during follow-ups. (b) Initial-Responders (17.6%) had marked symptom
reduction during treatment (p values � .001) and low depression severity at posttreatment, but increased
severity over follow-up (p value � .001). (c) Optimal-Responders (13.5%) achieved most gains during
early treatment (p value � .001), continued to improve (p value � .01) and maintained minimal
depression during follow-ups. The classes did not differ significantly on baseline measures or treatment
received, but differed on insomnia-related measures after treatment began (p values � .05): Optimal-
Responders consistently endorsed the lowest insomnia severity, sleep effort, and unhelpful beliefs about
sleep. Conclusions: Three depression symptom trajectories were observed among patients with comorbid
insomnia and MDD. These trajectories were associated with insomnia-related constructs after commenc-
ing treatment. Early changes in insomnia characteristics may predict long-term depression outcomes.
What is the public health significance of this article?
This study identified three distinct depression trajectories in patients with comorbid major depression
and insomnia disorders during treatment and 2-year follow-up. Those with the largest and most
sustained improvements in depression consistently scored the lowest on postbaseline insomnia and
insomnia-related cognitions. Early changes in insomnia symptoms and insomnia-related character ...
Dr. Michael H. Bloch - Simposio Internacional 'La enfermedad de la duda: el TOC'Fundación Ramón Areces
El 14 de noviembre de 2013, la Fundación Ramón Areces organizó y acogió en su sede un Simposio Internacional sobre 'La enfermedad de la duda: el TOC'. El Trastorno Obsesivo-Compulsivo (TOC) es un problema de salud pública, poco conocido, que afecta a un porcentaje de la población en torno a un 1-2% y que la Organización Mundial de la Salud ha situado entre las diez entidades que producen más discapacidad.
Cognitive-Behavioural Exposure Therapy for Multiple Chemical Sensitivity: A C...CrimsonpublishersPPrs
A case report of a woman treated with a multi-faceted cognitive-behavioral exposure therapy (CBET) for multiple chemical sensitivity (MCS) is presented. The patient reported substantial improvements in the severity of her somatic symptoms, catastrophic thinking about symptoms, and functioning. Improvements were maintained six months after treatment ended. It is hypothesized that CBET reduces symptoms by reducing central sympathetic activation, maladaptive thinking and avoidant behavior. Long-term efficacy of CBET for MCS should be examined in large clinical trials.
Presentation by Dr. Jacob Kagan on addiction psychiatry, covers the neurobiology of addiction, diagnosis and management od dually-diagnosed patients, relapse prevention, psycopharmacology interventions and more. http://www.jacobkaganmd.com
"..The proposed definition, therefore, is not intended to be prescriptive but represents a working framework. Clinicians and researchers should exercise their judgment in interpreting the principles described in this report when applying the definition to diverse settings.."
-- Kwan P, et al, 2017
Running Head Case study1Case study 5Case Stud.docxtodd271
Running Head: Case study 1
Case study 5
Case Study
Walden University
Name
NURS – 6630N
March 9, 2019
Case Study
Optimizing the dosing of medicines for neonates and children remains a challenge. The importance of pharmacokinetic (PK) and pharmacodynamics (PD) research is recognized both in medicines regulation and pediatric clinical pharmacology, yet there remain barriers to undertaking high-quality PK and PD studies. While these studies are essential in understanding the dose–concentration–effect relationship and should underpin dosing recommendations, this review examines how challenges affecting the design and conduct of pediatric pharmacological studies can be overcome using targeted pharmacometric strategies. Model-based approaches confer benefits at all stages of the drug life-cycle, from identifying the first dose to be used in children, to clinical trial design, and optimizing the dosing regimens of older, off-patent medications. To benefit patients, strategies to ensure that new PK, PD and trial data are incorporated into evidence-based dosing recommendations are needed.
The client selected is an African American child having depression with normal development milestone. Other aspects reveal that the child has high ratings in depression scale. The criterion is used to diagnose the child.
Decision point one
In this case, we had to prescribe the first choice of drug to get an effective effect. Some Selective serotonin reuptake inhibitors (SSRIs) are the drugs of choice to use in children with depressive disorder. The best medicine is Zoloft having sertraline. Now we decided the starting dose and that was 25mg to be administered orally. According to Vitiello (2012), if the medicine does not work in starting dose, we need to increase the dose. The child had been prescribed Zoloft and he came back with no change in his mental health.
Decision point two
If the drug is not working in a low dose, we need to increase the dose. Decision point two involved increasing the dose from 25mg to 50mg.The purpose of increasing the dose was to lower the depressive symptoms. Being within the range, we expected minimal desired effects (Stahl, 2013). Giving a single dose is more likely to give persistent desired effects in client. The patient experienced 50 percent decrease in symptoms. Hence Zoloft was successful in managing the patient’s depression. You must be cautious about the side effects of sertraline. One of the major is suicidal thoughts.
Decision point three
Decision point three is to decide if the dose will be maintained or increased to get rid of symptoms completely. The best decision is to maintain the dose because if the patient has shown 50 percent improvement then he will show more with the passage of time. His dose had been maintained now he further experienced decrease in symptoms. The best treatment is the complete remission as it is the main aim in contemporary psychopharmacology (Stahl, 2013). Then I recommended.
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These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
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1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
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5. Describe the cough and sneeze reflexes
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2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
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Title: Sense of Smell
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Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
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MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
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Odor Detection Threshold:
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Characteristics of Smell:
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Behavioral and emotional influences of smell.
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Primitive, less old, and new olfactory systems with different path
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RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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Dr Sadgun Bhandari - A PRELIMNARY REVIEW
1. CLINICAL IMPLICATIONS OF THE PLACEBO
RESPONSE
A PRELIMNARY REVIEW
Dr. Sadgun Bhandari
Consultant Psychiatrist
Queen Elizabeth II Hospital
Howlands
Welwyn Garden City
1
2. CLINICAL IMPLICATIONS OF THE PLACEBO
RESPONSE
QUESTION
ARE THERE ANY FINDINGS FROM THE
PLACEBO RESPONSE THAT COULD BE
USED IN THE TREATMENT OF
OUTPATIENTS WITH DEPRESSION
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3. CLINICAL IMPLICATIONS OF THE PLACEBO
RESPONSE
•
THE RATE OF PLACEBO RESPONSE IN ANTIDEPRESSANT
TRIALS IS FAIRLY CONSISTENT AT ABOUT 30 %
•
WHICH MEANS THAT ON AN AVERAGE 1 IN 3 PATIENTS DO
WELL WITH A PLACEBO
•
THE RESPONSE IS TRUE FOR SHORT TERM TRIALS OF
ANTIDEPRESSANTS WHICH USUALLY LAST ABOUT 6-12
WEEKS
•
DOES THAT MEAN THAT 1 IN 3 PATIENTS COULD IMPROVE
WITHOUT ACTIVE TREATMENT?
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4. PROBLEMS WITH DIAGNOSIS
• ARE THERE PROBLEMS WITH
DEPRESSION IS DIAGNOSED?
THE
WAY
• THERE IS VERY LITTLE IN THE LITERATURE WHICH
ADDRESSES THIS
• IN 1984 THERE WAS SOME CONCERN IN ONE
ARTICLE THAT PERHAPS THE DSM III WAS PRONE
TO INCLUDE MILDER CASES AND THE CRITERIA
NEEDED TO BE STRICTER
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5. CHARACTERISTICS OF PLACEBO
RESPONDERS
• Placebo responders were significantly more
likely to be nonendogenous and were more
likely to meet criteria for another Research
Diagnostic Criteria diagnosis. Additionally,
placebo responders were characterized by a
shorter length of illness and reported a lower
level of depressive symptomatology
•
•
Which depressions respond to placebo?
Fairchild CJ, Rush AJ, Vasavada N, Giles DE, Khatami M.
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6. CHARACTERISTICS
• STUDY LOOKING AT TRIAL CHARACTERISTICS FOUND THAT
SEVERITY
OF
SYMPTOMS
BEFORE
RANDOMISATION,
DOSING SCHEDULE, THE NUMBER OF TREATMENT ARMS
AND NUMBER OF FEMALE PATIENTS WERE MORE LIKELY TO
DIFFERENTIATE ANTIDEPRESSANT FROM PLACEBO
• KHAN A; KOLTS RL; THASE ME; KRISHNAN KRR; BROWN W
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7. RESPONSE IN ANTIDEPRESSANT TRIALS
ALONE?
We confirmed that placebo response in MDD is
large regardless of the intervention and is
associated with depression refractoriness and
treatment combination (add-on rTMS studies).
The magnitude of the placebo response seems
to be related with study population and study
design rather than the intervention itself.
Placebo Response of Non-Pharmacological and Pharmacological
Trials in Major Depression: A Systematic Review and Meta-Analysis
André Russowsky Brunoni1,2, Mariana Lopes1, Ted J. Kaptchuk3, Felipe
Fregni1
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8. PLACEBO RESPONDERS DURING LEAD IN
PERIOD
• Analysis of baseline and postplacebo measures showed
that the 10-day placebo responders in our sample were
convincingly depressed at baseline and improved
significantly after placebo washout. This group of patients
differed from 6-week placebo responders in our
randomized trials in being more mildly ill, being more
chronic, containing fewer cases of primary depression,
and having fewer illness precipitants. They differed from
placebo nonresponders largely in manifesting milder
illness symptoms across the range of psychopathology.
The proportion of placebo washout responders declined in
the winter months
•
•
Baseline characteristics of 10-day placebo washout responders in
antidepressant trials.
Rabkin JG, Stewart JW, McGrath PJ, Markowitz JS, Harrison W, Quitkin FM.
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9. PLACEBO RESPONDERS DURING LEAD
IN PERIOD
• Depressed patients who showed significant improvement
after a 10-day placebo washout trial were followed for 3
months. Twenty-five relapsed and 20 remained well.
Relapsing patients more frequently had a family history
of depression, more had prior psychiatric treatment, their
illness course was more chronic once ill, mean age of
onset was younger, and fewer had obvious precipitants.
More relapsers had RDC diagnoses of intermittent
depressive disorder. Among those with major depressive
disorder, fewer relapsers met subtype criteria for simple,
situational, or recurrent. Nonaffective psychiatric
disorders were present in 64% of relapsers and no
placebo responders who remained well. Rabkin JG,
McGrath P, Stewart JW, Harrison W, Markowitz JS, Quitkin F.
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10. DOES THE PLACEBO RESPONSE PERSIST
One study looked at 3063 patients who
were continued on placebo after the
first 12 weeks . 79% of placebo
responders remained well.
The persistence of the placebo response in
antidepressant clinical trials
Khan A; Redding N and Brown WA
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11. ELDERLY
Placebo response is high in the elderly as well and
one study found lower levels of cognitive and
sleep disturbance leading to a better response
to placebo.
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12. PAEDIATRIC DEPRESSION
RATES ARE VERY HIGH.
A META-ANALYSIS FOUND THAT THE SINGLE
MOST SIGNIFICANT PREDICTOR WERE THE
NUMBER OF SITES.
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13. WHAT CAUSES THE PLACEBO
RESPONSE IN DEPRESSION
• Change in any placebo group occurs for three
main reasons: the encouraging effect of being in
treatment, the effect of spontaneous remission
while in treatment, and because people with
chronic symptoms normally seek help when their
symptoms are worst and, through natural
fluctuations in severity, are likely to be improved
when next assessed.
• Andrews (2001)
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14. WHAT CAUSES THE PLACEBO
RESPONSE IN DEPRESSION
• Good clinical care (Andrews, 1993) consists of
a review of what the patient did and did not do,
with encouragement to resolve problems and
resume positive activity. Structured problemsolving and activity scheduling are systematic
approaches to achieve these goals (MynorsWallis et al, 1995; Andrews & Jenkins, 1999)
that have been demonstrated in randomised
controlled trials to be effective.
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15. WHAT CAUSES THE PLACEBO
RESPONSE IN DEPRESSION
• McLeod et al (1992) reported from a sample of
married persons that the median duration of
DSM-III-R (American Psychiatric Association,
1987) episodes of depression was 10 weeks,
with 75% having episodes of under 22 weeks.
Kendler et al (1997) studied a population sample
of women and found a median time to recovery
of 6 weeks, with 75% recovering in 12 weeks.
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16. WHAT CAUSES THE PLACEBO
RESPONSE IN DEPRESSION
• If the population time to recovery were a median
of 8 weeks and 75% recovered within 16 weeks,
then people recruited into a trial after being
depressed for 8 weeks would have a 50%
chance of remitting during the conduct of the
usual 8-week trial. These two factors, response
to encouragement and a 50% probability of
spontaneous remission during the trial, could
account for the considerable progress of
placebo control groups in depression trials.
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17. PERCEIVED PLACEBO
EFFECT?
• Placebo effect
• There is a distinction between a “true placebo effect”
versus a “perceived placebo effect.”9 A true placebo
effect depends on factors such as the attitudes of the
physician and the patient, the suggestibility of the
patient, and the type of treatment.9 A perceived placebo
effect results from the influence of such factors as the
natural course of the disease, the tendency of most
measures of biological variation to regress toward the
mean, and unidentified parallel interventions (eg,
patients receiving extra attention during a clinical trial,
becoming more aware of the problem, and taking actions
that influence outcome).9
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18. CONCLUSIONS
CLEARLY THE PLACEBO RESPONSE IS HIGH
AND PERSISTENT IN DEPRESSION AND
OCCURS ACROSS THE WHOLE AGE RANGE.
NOT CLEAR IF THIS IS TO WITH THE WAY
DEPRESSION IS DIAGNOSED.
SEVERITY SEEMS TO BE A SIGNIFICANT
ISSUE
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19. CONCLUSIONS
DOES THIS MEAN THAT WHEN WE SEE
MILDER CASES OF DEPRESSION WE COULD
CONSIDER NOT STARTING AN
ANTIDEPRESSANT STRAIGHTAWAY.
IT WOULD BE IMPORTANT TO CARRY ON
PROVIDING FOLLOW-UP IN THE SHORT
TERM TO MAKE SURE THAT THE PSYCHOSOCIAL ASPECTS OF TREATMENT
CONTINUE.
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20. WAITFUL WATCHING
• Dago and Quitkin4 suggest that, before deciding
on whether or not to prescribe an
antidepressant, clinicians should monitor the
elements of the physician-patient relationship
that may affect the patient's expectation or hope
of being helped by the medication. These
authors also recommend that a clinician follow
those patients who demonstrate an early clinical
improvement without antidepressant treatment
until they have two unimproved weeks, and only
then prescribe an antidepressant.
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