ResumoRelatamos o caso de uma paciente com diagnóstico de esquizofrenia paranóide que desenvolveu dois quadros de hepatotoxicidade atribuídos a efeitos colaterais do ácido valpróico e da clozapina. Essa relação foi estabelecida pela proximidade temporal entre o início da medicação e a instalação do quadro, pela resolução deste após a suspensão da medicação e pela exclusão de outras causas de doença hepática. No seguimento, o controle clínico da paciente foi realizado com eletroconvulsoterapia (ECT). Salientamos a importância da vigilância cuidadosa dos efeitos adversos de psicofármacos, especialmente sobre a função hepática, e da ECT como possibilidade terapêutica diante de limitações farmacológicas. Palavras-chave: hepatotoxicidade, ácido valpróico, clozapina, eletroconvulsoterapia. AbstractWe report the case of a patient with paranoid schizophrenia who developed two episodes of severe hepatotoxicity. They were attributed to the side effects of valproic acid and clozapine. This relationship was established by the temporal proximity between the onset of medication and the development of side effects, the clinical remission after drug cessation and the exclusion of other causes of hepatic diseases. On the follow-up, the patient was treated with eletroconvulsive therapy. This case report highlights the relevance of careful vigilance of adverse effects of psychotropics, especially hepatotoxicity, and the role of eletroconvulsive therapy when there are pharmacological constraints.
symptom reduction there is still poor functional recovery following a first psychotic episode: about the same percentage fail to demonstrate former social and occupational functioning or quality of life within 6 months after starting pharmacological treatment despite symptom recovery. These functional impairments are present up to 5 years after illness onset even when optimal pharmacological treatment is provided. Different studies point out that deficits in neurocognition (e.g. attention, memory, executive functioning) and social cognition (e.g. emotion and social perception, insight, social schema, attributional style) might be a main source for explaining this poor functional outcome. Against this background our research group in Bern has developed therapy programs focussing especially on neuro-and social cognition. Integrated Psychological Therapy (IPT) was tested in 32 controlled studies in different countries with a total sample of 1420 patients. A further development of IPT is the Integrated Neurocognitive Therapy (INT) that is evaluated in a still ongoing multi-centre study. Data of a metanalysis of IPT and first results with 28 patients of the INT study indicate beneficial improvements in neuro-and social cognition, self-efficacy and self-perceived quality of life. These results confirm the importance of psychological therapies in combination with pharmacological treatment to optimize functional outcome and recovery.
Several studies provided evidence that relationship of cognitive impairment with social functioning is stronger than that of psychopathology. In a group of 88 subjects with schizophrenia or schizoaffective disorders we found that verbal memory, executive function and sustained attention indices explained 19.9% of the global disability variance, while negative symptoms explained 4.4% of the variance.Based on these data our group designed an individualized rehabilitation program including two one-hour sessions of computerized cognitive training and one two-hour session of social skills training per week (Social Skills And Neurocognitive Individualized Training, SSANIT).In the present study the efficacy of this rehabilitation program was investigated in 58 subjects with chronic schizophrenia or schizoaffective disorder. Patients were recruited in three Mental Health Departments located in the South of Italy and randomly allocated to one of two rehabilitation programs: SSANIT or Usual Rehabilitation Activities (URA) of each department. The active treatment phase lasted 6 months.At the end of treatment a significant improvement of psychosocial functioning (global psychosocial index, participation in family life and availability to work) was found in the SSANIT but not in the URA group; furthermore a worsening of the negative dimension was observed in the URA, but not in the SSANIT group.According to our findings, the SSANIT program is more effective than the rehabilitation activities usually implemented in Mental Health Departments (e.g. carpentry and decoupage).
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