Objective-We aimed to investigate the efficacy of 20 Hz repetitive transcranial magnetic stimulation (rTMS) of either right or left dorsolateral prefrontal cortex (DLPFC) as compared to sham rTMS for the relief of posttraumatic stress disorder (PTSD)-associated symptoms.Method-In this double-blind, placebo-controlled phase II trial conducted between October 2005 and July 2008, 30 patients with DSM-IV-diagnosed PTSD were randomly assigned to receive 1 of the following treatments: active 20 Hz rTMS of the right DLPFC, active 20 Hz rTMS of the left DLPFC, or sham rTMS. Treatments were administered in 10 daily sessions over 2 weeks. A blinded rater assessed severity of core PTSD symptoms, depression, and anxiety before, during, and after completion of the treatment protocol. In addition, a battery of neuropsychological tests was measured before and after treatment. Results-Resultsshow that both active conditions-20 Hz rTMS of left and right DLPFCinduced a significant decrease in PTSD symptoms as indexed by the PTSD Checklist and Treatment Outcome PTSD Scale; however, right rTMS induced a larger effect as compared to left rTMS. In addition, there was a significant improvement of mood after left rTMS and a significant reduction of anxiety following right rTMS. Improvements in PTSD symptoms were long lasting; effects were still significant at the 3-month follow-up. Finally, neuropsychological evaluation showed that active 20 Hz rTMS is not associated with cognitive worsening and is safe for use in patients with PTSD.Conclusions-These results support the notion that modulation of prefrontal cortex can alleviate the core symptoms of PTSD and suggest that high-frequency rTMS of right DLPFC might be the optimal treatment strategy. Although selective serotonin reuptake inhibitors (SSRIs)-among other antidepressantshave resulted in various degrees of improvement in patients with PTSD, there is no definitive pharmacotherapy available to date for the treatment of this debilitating disorder. A review of 37 clinical trials of pharmacotherapies 4 found inadequate evidence to determine the value of antidepressants, benzodiazepines, anticonvulsants, α-blockers, and secondgeneration antipsychotics for the treatment of PTSD. Even so, according to an American Psychiatric Association guideline, 5 SSRIs remain the first line of treatment for PTSD. In addition, due to the complex nature of this disorder, individuals with PTSD also seem to benefit from 10 to 12 sessions of cognitive-behavioral therapy, prolonged-exposure therapy, or cognitive-processing therapy. Nevertheless, many individuals respond inadequately to currently available therapies, and research for more effective treatment paradigms is ongoing. NIH Public AccessMost recently, repetitive transcranial magnetic stimulation (rTMS)-a method of noninvasive neuromodulation-has been emerging as a potentially effective technique in the treatment of PTSD. Indeed, rTMS has already been shown to be highly effective in the treatment of medically refractory depression 6 and is n...

Suicide is a global public health problem that causes the loss of more than 800,000 lives each year, principally among young people. In Brazil, the average mortality rate attributable to suicide is approximately 5.23 per 100,000 population. Although many guidelines have been published for the management of suicidal behavior, to date, there are no recent guidelines based on the principles of evidence-based medicine that apply to the reality of suicide in Brazil. The objective of this work is to provide key guidelines for managing patients with suicidal behavior in Brazil. This project involved 11 Brazilian psychiatry professionals selected by the Psychiatric Emergencies Committee (Comissã o de Emergê ncias Psiquiá tricas) of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. For the development of these guidelines, 79 articles were reviewed (from 5,362 initially collected and 755 abstracts). In this review, we present definitions, risk and protective factors, assessments, and an introduction to the Safety Plan. Systematic review registry number: CRD42020206517

This article continues our presentation of the Brazilian Psychiatric Association guidelines for the management of patients with suicidal behavior, with a focus on screening, intervention, postvention, prevention, and promotion. For the development of these guidelines, we conducted a systematic review of the MEDLINE (via PubMed), Cochrane Database of Systematic Reviews, Web of Science, and SciELO databases for research published from 1997 to 2020. Systematic reviews, clinical trials, and cohort/observational studies on screening, intervention, and prevention in suicidal behavior were included. This project involved 14 Brazilian psychiatry professionals and 1 psychologist selected by the Psychiatric Emergencies Committee of the Brazilian Psychiatric Association for their experience and knowledge in psychiatry and psychiatric emergencies. Publications were evaluated according to the 2011 Oxford Center for Evidence-Based Medicine (OCEBM) Levels of Evidence Classification. Eightyfive articles were reviewed (of 5,362 initially collected and 755 abstracts on the drug approach). Forms of screening, intervention, and prevention are presented. The intervention section presents evidence for psychotherapeutic and drug interventions. For the latter, it is important to remember that each medication is effective only for specific groups and should not replace treatment protocols. We maintain our recommendation for the use of universal screening plus intervention. Although the various studies differ in terms of the populations evaluated and several proposals are presented, there is already significant evidence for certain interventions. Suicidal behavior can be analyzed by evidence-based medicine protocols. Currently, the best strategy is to combine several techniques through the Safety Plan. Nevertheless, further research on the topic is needed to elucidate some approaches with particular potential for intervention and prevention.

The Portuguese version of the DRS-R-98 is a valid and reliable measure of delirium that distinguishes delirium from other disorders and is sensitive to change in delirium severity, which may be of great value for longitudinal studies.

Introdução: A pandemia por COVID-19 exacerbou a angústia existencial em relação a morte. A insegurança e incerteza relacionadas aos limites da ciência, devido à falta de consenso científico sobre essa nova doença, convocam a necessidade de investigar, refletir e revisar as informações sobre problemas de saúde mental vinculados ao trabalho médico, especialmente para os que estão na linha de frente da assistência a pessoas com COVID-19, bem como discutir o estigma relacionado ao sofrimento psíquico desta população, em especial nesta pandemia, e identificar precocemente possíveis adoecimentos psíquicos e facilitar à busca imediata de assistência em saúde mental. Métodos: revisão narrativa visando discutir o estado da arte e atualização do conhecimento sobre o adoecimento psíquico dos médicos na pandemia do COVID-19. Discussão: A literatura aponta que discentes, residentes, docentes e profissionais da Medicina apresentam importantes prevalências de Transtorno Mental Comum, Sintomas Depressivos, Burnout e Suicídio. A pandemia de COVID-19 apresenta um risco de aumento de prevalência de transtornos mentais, comumente referida como quarta onda da pandemia, associada a elementos biopsicossociais do período de quarentena e priorização dos cuidados físicos em detrimento dos psíquicos. Conclusões: Instituições de saúde devem realizar uma reflexão profunda sobre o seu papel na promoção, manutenção e a criação de atividades e de programas de prevenção do sofrimento psíquico ou transtornos mentais identificados nos profissionais médicos que lá atuam. Estas contribuirão para o planejamento de melhores estratégias que preservem a saúde mental destes com consequências positivas na sociedade como um todo.