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  • About
  • The Global ETD Search service is a free service for researchers to find electronic theses and dissertations. This service is provided by the Networked Digital Library of Theses and Dissertations.
    Our metadata is collected from universities around the world. If you manage a university/consortium/country archive and want to be added, details can be found on the NDLTD website.
241

Mulheres em programa regular de atividade física: ansiedade, depressão, fadiga, burnout e qualidade de vida.

Nagamine, Kazuo Kawano 18 May 2007 (has links)
Made available in DSpace on 2016-01-26T12:51:16Z (GMT). No. of bitstreams: 1 kazuokawanonagamine_tese.pdf: 4436335 bytes, checksum: c1b23fd4cca930ca5e5a4810a91ebb78 (MD5) Previous issue date: 2007-05-18 / There is much evidence about the positive impact of physical activity on health, including reduction in morbimortality, and improvement in the general wellbeing. Regularly practicing physical activities reduces anxiety, stress, depression and burnout, enhances personal relationships and performance at work, reduces absenteeism and improves quality of life. The objectives of this study were to prospectively assess anxiety, depression, fatigue, burnout and quality of life in individuals before, during, and after their participation in a sixmonth physical activity program conducted at work. Wilcoxon test was used to analyze quantitative variables. A qualitative analysis of the participant s impressions of the program was also performed. Participants: female employees who answered to an advertisement affirming their availability for the program, met inclusion criteria (sedentary women, working 40 hours per week, no health problems, 75% of frequency in the program) and agreed to participate (mean age: 35 years old; SD: 7.5 years). Method: After a physical examination, anamnesis, anthropometrical assessment and testing to obtain heart rate, the participants joined a twice-weekly physical activity program after work that included: walking and/or jogging and localized exercise training (calisthenics exercise). On starting, and after three and six months of the program all participants completed the Beck Depression Inventory, Beck Anxiety Inventory, Chalder Fatigue Scale, Maslach Burnout Inventory and a measure of quality of life (QL) SF-36. Additionally, after six months, participants filled out a questionnaire about their participation in the program. Results: 39 participants xvi started the program, 17 remained until at least the third month and 12 completed the six months. Anxiety symptoms decreased from slight to minimal. There was a significant reduction in depressive symptoms (p=0.006), in fatigue (p=0.01) and burnout (p=0.02). There was an increase in all aspects of QL, with a significant increase in vitality (p=0.04). Participants who abandoned the program reported they did so because of domestic chores, academic activities and work. The highlighted positive aspects of the program were improved relationship with colleagues, wellbeing, health and benefits at work. Conclusions: Data from the study endorse reported benefits of regularly practicing physical activity. The positive testimonies by the participants and observed benefits, stress the importance of implementing this type of program, which can be conducted in the work place at a low cost. / Existem atualmente evidências a respeito do impacto positivo da prática de atividade física sobre a saúde, como redução da morbimortalidade relacionada a diversas doenças e aumento do bem-estar geral. A prática regular de atividade física reduz níveis de ansiedade, estresse, depressão e burnout, aprimora a relação interpessoal, o rendimento laboral, reduz o absenteísmo e promove qualidade de vida. Este estudo teve como objetivos avaliar prospectivamente sintomas de ansiedade, depressão, fadiga, burnout e qualidade de vida em funcionárias, antes, durante e após a participação em programa de atividade física regular durante seis meses, oferecido dentro da própria instituição. Os dados foram analisados com o teste estatístico não paramétrico Wilcoxon do sinal. Análise qualitativa da perspectiva das participantes sobre o programa foi também realizada. Casuística: funcionárias que responderam a anúncio sobre disponibilidade do programa, atenderam aos critérios de inclusão (sedentárias, regime de trabalho de 40 horas semanais, sexo feminino, freqüência de 75% e ausência de problemas de saúde) e concordaram em participar (média de idade: 35; dp:7,5). Método: Após exame físico, anamnese, avaliação antropométrica e treino para obter freqüência cardíaca, as participantes iniciaram programa de atividade física (duas vezes por semana, após o expediente: caminhada e/ou corrida e ginástica localizada. No início, no terceiro e após o sexto mês no programa todas responderam aos Inventários Beck de Ansiedade e de Depressão, Escala de Fadiga de Chalder, Inventário Maslach de Burnout, Medida de Qualidade de Vida (QV) SF-36. Após o sexto mês responderam a questionário sobre sua participação no programa. Resultados: Das 39 participantes iniciais, 17 continuaram até o terceiro mês e 12 até o sexto. Os sintomas de ansiedade passaram da classificação "leve" para mínima". Houve redução significante dos sintomas de depressão (p=0,006), de fadiga (p=0,01) e de burnout (p=0,02). Nota de Resumo Houve aumento em todos os domínios de QV, com aumento significante da Vitalidade (p=0,04). As justificativas fornecidas pelas participantes em relação ao abandono do programa incluíram principalmente atividades domésticas, acadêmicas e de trabalho. Os benefícios apontados incluíram relacionamento com colegas, bem-estar, melhora na saúde, no trabalho e na auto-estima. Conclusões: Os dados obtidos são compatíveis com os benefícios da prática regular de atividade física. A avaliação positiva da experiência pelas participantes e os benefícios observados indicam a relevância de programas como este, que podem ser realizados no próprio ambiente de trabalho e são de baixo custo.
242

Associação entre consumo de ácidos graxos ômega 3 e transtorno de ansiedade: análise transversal do Estudo Longitudinal de Saúde do Adulto (ELSA-Brasil) / Omega 3 consumption and anxiety disorders: a cross-sectional analysis of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Lara Cristiane Natacci 01 August 2018 (has links)
oucos estudos avaliaram a associação da ingestão de ácidos graxos ômega 3 e transtornos de ansiedade. O presente estudo utilizou dados transversais do exame de linha de base (2008-2010) do Estudo Longitudinal Brasileiro de Saúde do Adulto - ELSA-Brasil para avaliar essa associação. A exposição dietética foi medida por um questionário quantitativo de frequência alimentar validado para a população brasileira e adaptado para o estudo, e os diagnósticos mentais foram avaliados pelo Clinical Interview Schedule-Revised Version - CIS-R, diagnosticando transtornos mentais de acordo com a Classificação Internacional de Doenças - CID-10. Modelos de regressão logística foram construídos utilizando quintis do consumo de ácidos graxos ômega 3, ácidos graxos ômega 6, razão de consumo n-6/n-3, e ácidos graxos poli-insaturados, usando o primeiro quintil como referência. Dos 15.105 sujeitos participantes do ELSA-Brasil, foram excluídos aqueles que relataram ingestão de menos de 500 ou mais de 4000 kcal, aqueles que relataram ingestão de suplementos n-3 ou n-6 e aqueles que foram submetidos a cirurgia bariátrica. Após as exclusões, 12268 participantes permaneceram na análise, dos quais 1893 (15,4%) apresentaram transtornos de ansiedade. Os indivíduos com transtorno de ansiedade eram mais jovens, de sexo feminino, menor escolaridade e renda, referiram tabagismo atual e atividade física mais leve. Valores mais altos de IMC e de proteína C reativa de alta sensibilidade foram observados nos indivíduos com ansiedade. A ingestão diária média de ácido eicosapentaenoico (EPA), ácido docosapentanoico (DPA) e ácido docosaexaenoico (DHA) foi significativamente menor em participantes com ansiedade. Um maior consumo desses três ácidos graxos da família ômega-3 foi observado em indivíduos com mais idade, maior renda e escolaridade, com dislipidemia, consumo de álcool e tabagismo atuais, e prática de atividade física vigorosa. Após o ajuste para variáveis sociodemográficas (idade, sexo, etnia e educação) fatores de risco cardiovascular (hipertensão, diabetes, dislipidemia, tabagismo, ingestão de álcool e atividade física), calorias totais, qualidade da dieta e depressão, os participantes do quinto quintil de ingestão de EPA, DHA e DPA mostraram associação inversa com transtornos de ansiedade: OR 0,82 (IC 95%, 0,69-0,98), OR 0,83 (IC 95%, 0,69-0,98) e OR 0,82 (IC 95%, 0,69-0,98), respectivamente. Participantes no quinto quintil de razão ômega-6/ômega-3 tiveram associação positiva com transtornos de ansiedade. Nenhuma associação foi encontrada com a ingestão de PUFA, ou ômega-3 e ômega-6 isoladamente com ansiedade após os ajustes. Nesta análise, uma alta ingestão de ômega-3 EPA, DHA e DPA foi inversamente associada com a presença de transtornos de ansiedade, enquanto que a alta razão ômega-6/ômega-3 foi diretamente associada à presença desses transtornos, sugerindo um possível efeito protetor dos ácidos graxos omega-3 EPA, DPA e DHA contra a ansiedade / Few studies have evaluated the association of omega-3 fatty acids intake and anxiety disorders. The present study used cross-sectional data from the baseline (2008-2010) examination of the Brazilian Longitudinal Study of Adult Health - ELSA-Brazil to evaluate this association. The dietary exposure was measured by a quantitative food frequency questionnaire validated for the brazilian population and adapted for the study, and the mental diagnoses were assessed by the Clinical Interview Schedule-Revised Version (CIS-R), diagnosing mental disorders according to the International Classification of Diseases - ICD-10. Logistic regression models were built using quintiles of omega-3 fatty acids, omega-6 fatty acids, omega-6/omega-3 ratio, and polyunsaturated fatty acids consumption, using the first quintile as a reference. Of the 15,105 subjects participating in ELSA-Brazil, those who reported ingestion of less than 500 or more than 4000 kcal, those who reported ingestion of omega-3 or omega-6 supplements and those had undergone bariatric surgery were excluded. After exclusions, 12,268 participants remained in the analysis, of whom 1893 (15.4%) had anxiety disorders. Subjects with anxiety disorder were younger, female, had lower education and income, reported current smoking and mild physical activity. Higher values of BMI and high sensibility C reactive protein were observed in subjects with anxiety. The mean daily intakes of eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA) and docosahexaenoic acid (DHA) were significantly lower in subjects with anxiety. A higher intake of these three omega-3 fatty acids was observed in older individuals with higher income and education, with current dyslipidemias, alcohol consumption and smoking, and vigorous physical activity. After adjustment for socio-demographic variables (age, sex, ethnicity and education), cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking, alcohol intake and physical activity), total calories, diet quality and depression, EPA, DHA and DPA intakes showed an inverse association with anxiety disorders: OR 0.82 (95% CI, 0.69-0.98), OR 0.83 (95% CI, 0.69-0.98) and OR 0.82 (95% CI, 0.69-0.98), respectively. Participants in the fifth quintile of omega-6/omega-3 ratio had a positive association with anxiety disorders. No association was found with ingestion of PUFA, or omega-3 and omega-6 alone with anxiety after adjustments. In this analysis, a high intake of omega-3 EPA, DHA and DPA was inversely associated with the presence of anxiety disorders, while the higher omega-6 omega-3 ratio was directly associated with the presence of these disorders, suggesting a possible protector effect of omega-3 fatty acids EPA, DPA and DHA against anxiety
243

Tratamento do transtorno obsessivo-compulsivo resistente com estimulação magnética transcraniana de repetição (EMTr): um estudo duplo-cego controlado / Treatment of resistant obsessive-compulsive disorder with repetitive transcranial magnetic stimulation (rTMS): a double-blind, placebo controlled trial

Carlos Gustavo Sardinha Mansú 29 June 2010 (has links)
Introdução: O presente estudo tem como objetivo avaliar a eficácia da estimulação magnética transcraniana de repetição (EMTr) em freqüência excitatória, aplicada ao córtex pré-frontal dorsolateral direito (CPFDLd), quando adicionada ao tratamento vigente de pacientes com transtorno obsessivocompulsivo (TOC) resistente. Método: 30 pacientes com TOC resistente ao tratamento foram alocados aleatoriamente para receber EMTr ativa ou placebo, sendo que a condição de tratamento permaneceu oculta para pacientes e avaliador. O tratamento vigente permaneceu estável por ao menos 8 semanas. A EMTr foi realizada com uma bobina em formato de oito à freqüência de 10Hz, com 110% do limiar motor em 30 sessões diárias de 40 séries de 5 segundos com 25 segundos de intervalo. A gravidade dos sintomas foi avaliada inicialmente, após 2 e 6 semanas de tratamento e 2 e 6 semanas de seguimento com a escala de Yale-Brown para avaliação de sintomas obsessivo-compulsivos (Y-BOCS), Escala de Impressão Clínica Global (CGI), Escala de Hamilton para ansiedade (HAM-A), Escala de Hamilton para depressão com 17 itens (HAM-D17), e inventário SF-36 de qualidade de vida. A medida primária de eficácia foi definida como redução de 30% ou mais nos escores da Y-BOCS e avaliação melhor ou muito melhor na sub-escala de melhora clínica da CGI ao término do seguimento. Resultados: A análise da medida primária de eficácia revelou que apenas um paciente em cada grupo preencheu critérios de resposta para o tratamento com EMTr (P=1.00). A análise de medidas repetidas dos escores de Y-BOCS mostrou um efeito significativo do tempo (F=7.33, P=0.002). Entretanto, não foi observada diferença entre os grupos ou interação grupo/tempo. A análise de medidas repetidas da CGI (gravidade), HAM-D17 e HAM-A também mostrou efeito significativo do tempo (P<0.001, =0.001 e <0.001 respectivamente), novamente sem diferença significativa entre os grupos ou interação. Conclusão: EMTr excitatória aplicada ao CPFDLd de pacientes com TOC resistente ao tratamento não foi diferente de placebo na redução de sintomas obsessivo-compulsivos ou melhora da impressão clínica global. Entretanto, ocorreu uma resposta placebo significativa / Introduction: The present study aims to evaluate the efficacy of added excitatory repetitive transcranial magnetic stimulation (rTMS), applied to the right dorsolateral prefrontal cortex in patients with treatment resistant obsessive-compulsive disorder (OCD). Methods: 30 treatment resistant OCD outpatients were randomized to receive either active or sham rTMS, remaining both patients and rater blind to treatment condition. Baseline treatment was kept stable for at least 8 weeks, and rTMS was performed with a figure-of-eight coil at 10Hz, 110% of motor threshold at 30 daily sessions of 40 trains of 5 seconds with 25 seconds interval. Symptom severity was determined at baseline and after 2 and 6 weeks of treatment and further 2 and 6 weeks of follow-up, using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), Clinical Global Impression Scale (CGI), Hamilton Anxiety Rating Scale (HAM-A), Hamilton Depression Rating Scale (HAM-D17) and SF-36 quality of life inventory. The primary outcome measure was defined as 30% or more improvement in Y-BOCS scores and a much improved or improved score at the CGIimprovement subscale by the end of follow up. Results: The analysis of primary outcome measure revealed that only one patient on each group met response criteria for treatment with rTMS (P=1.00). Repeated-measures analysis of Y-BOCS scores showed a significant effect of time (F=7.33, P=0.002). However, no significant group effect or group by time interaction was observed. Repeated measures analysis of CGI (severity), HAM-D17 and HAM-A also showed a significant effect of time (P<0.001, =0.001 and <0.001 respectively) with no significant group effect or group by time interaction. Conclusion: Excitatory rTMS delivered to the rDLPFC of treatment resistant OCD patients was not different from placebo in reducing obsessive-compulsive symptoms or improving clinical global impression. However, a significant placebo response occurred
244

The waxing and waning of mental disorders: Evaluating the stability of syndromes of mental disorders in the population

Wittchen, Hans-Ulrich, Lieb, Roselind, Pfister, Hildegard, Schuster, Peter 05 April 2013 (has links) (PDF)
This article examines the stability of symptoms, syndromes, and diagnoses of specific anxiety and depressive disorders, as well as diagnostic shifts from one syndrome to another over time. Using retrospective and longitudinal prospective data from the baseline and first follow-up investigation (19.7 months later) of the Early Developmental Stages of Psychopathology Study (EDSP), we focus on establishing stability measures for early stages of mental disorders in a community sample of adolescents aged 14 to 17 years at baseline. The results are as follows: (1) Although only about 30% developed a full-blown DSM-IV disorder, psychopathological syndromes are widespread in adolescents: 15% of the population aged 14 to 17 at baseline were not affected by at least some clinically relevant symptoms of mental disorders either throughout their previous life or throughout the follow-up period. (2) The likelihood of staying free of symptoms and threshold disorders during follow-up was highest among subjects who were completely well at baseline. The probability of a positive outcome decreased as a function of severity of baseline diagnostic status. (3) There was a considerable degree of fluctuation not only in the diagnostic status and severity of specific disorders, but also in terms of complete remissions and shifts from one syndrome and disorder to another. (4) Anxiety disorders, overall, slightly differ with regard to the persistence and stability of the diagnostic status from depressive disorders. (5) However, there were remarkable differences between specific types of anxiety and depressive disorders. Consistent with other longitudinal epidemiological studies in the general population, this study finds that the syndromes and diagnoses of mental disorders have a strong tendency to wax and wane over time in this age group.
245

Kosten-Effektivitäts- und Kosten-Nutzen-Analyse psychologischer Angstbehandlung / Psychological treatment of anxiety disorders: cost-effectiveness- and cost-benefit-analysis

Jacobi, Frank 27 May 2002 (has links) (PDF)
Aims: To assess effectiveness and economic benefit of the psychological treatment of anxiety disorders in order to compare them with the consumed resources of the treatment. Methods: Assessment of specific and non-specific symptoms and impairments in N=493 anxiety patients (DSM-IV) receiving cognitive behavior therapy pre, post, and one year after treatment with various measures. Additional analyses of costs of the treatment and the benefits due to reduced work disability and health care utilization after therapy (including a pilot study using a willingness-to-pay approach). The treatment setting can be characterised as clinically typical for everyday practice. Core results: a) effectiveness: Effect sizes ranged from 0.9 to 1.9. All improvements were significant and lasted until 1-year-follow-up. Rates of clinically significant therapy success ranged from 63% to 79% depending on outcome measure and success criteria. b) cost-effectiveness analysis: Cost-effectiveness-indices ranged from DM 8338.- to DM 10456.- for one successful treatment (average costs taking also the costs of unsuccessful treatments into account). c) cost-benefit-analysis: Cost reduction in the year after therapy was remarkable (inpatient costs about 25%, other cost factors 87%-100%), resulting in a benefit of DM 3026.- per patient and a cost-benefit-ratio of 1:0.58 in the first year after treatment. Assuming that the improvements are stable, the cost-benefit-ratio after five years would be estimated as 1:2.63. Discussion: The present study shows exemplarily for CBT of anxiety disorders that modern psychotherapy can produce remarkable results at reasonable costs. Furthermore, clinical-psychological treatment methods show an additional economic benefit. Clinical Psychology can benefit from focusing not only the promising developments in classification, etiology, and treatment but also taking over the cost perspective (which is relatively new in scientific evaluation of psychotherapy). (Appendix: Cost-Benefit-Calculator.htm; 8,97 KB -- Usage: Referat Informationsvermittlung/ SLUB) / Fragestellungen: Ermittlung von Effektivität und monetärem Nutzen psychologischer Behandlung von Angststörungen, die dann den für die Therapie aufgewendeten Ressourcen gegenübergestellt werden. Methoden: N=493 Patienten mit Angststörungen (DSM-IV), die eine ambulante störungsspezifische kognitive Verhaltenstherapie absolviert haben, wurden prä, post und zur 1-Jahres-Katamnese untersucht. Das Spektrum der Erhebungen umfasste störungsspezifische und störungsübergreifende Symptombelastung und Beeinträchtigungen in verschiedenen Lebensbereichen, sowie eine globale Therapieerfolgseinschätzung von Patienten und Therapeuten. In einer zweiten Studie wurden zusätzlich an einer Teilstichprobe Kosten-Nutzen-Aspekte untersucht (Einsparungen durch Reduktion von Gesundheitsleistungen und Arbeitsunfähigkeit; außerdem Pilotstudie zu willingness-to-pay-Ansatz). Das Behandlungssetting der Studie ist charakterisiert durch klinisch relevante Rahmenbedingungen und Praxisnähe. Zentrale Ergebnisse: a) Effektivität: Die Effektstärken reichten in Abhängigkeit von der Meßmethode von 0.9 bis 1.9. Die Verbesserungen waren durchgängig signifikant und blieben bis zur 1-Jahres-Katamnese stabil. Die Raten klinisch bedeutsamer Besserungen betrugen 63% - 79% in Abhängigkeit von Mess- und Auswertungsmethode. b) Kosten-Effektivitäts-Analyse: Die Kosten-Effektivitätivitäts-Indices betrugen DM 8338.- bis DM 10456.- (dieser Index gibt an, was eine erfolgreiche Behandlung durchschnittlich kostet, also unter Einbezug der nicht erfolgreichen Behandlungen in die Gesamtkosten). c) Kosten-Nutzen-Analyse: Im Jahr nach Therapie reduzierten sich die Kostenfaktoren der Störungen vor Therapie beträchtlich (stationäre Kosten um 25%, restliche Kostenfaktoren 87% - 100%). Die dadurch erzielten Einsparungen betrugen durchschnittlich DM 3026.- (Kosten-Nutzen-Verhältnis im ersten Jahr: 1 : 0.58). Unter der Annahme, dass die Auswirkungen der Therapie auch über die 1-Jahres-Katamnese hinaus stabil bleiben, kann man abschätzen, dass sich die Therapie innerhalb des zweiten Jahres amortisiert und das Kosten-Nutzen-Verhältnis nach fünf Jahren (diskontiert) 1 : 2.63 beträgt. Diskussion: Wie in dieser Arbeit anhand der kognitiven Verhaltenstherapie für Angststörungen gezeigt wird, kann moderne Psychotherapie bei vertretbarem Aufwand beachtliche Erfolge verbuchen. Klinisch-psychologische Behandlungsmethoden sind darüber hinaus auch wirtschaftlich, derart, dass sie über den reinen Behandlungserfolg hinaus zu Kosteneinsparungen beitragen könnten. Es ist erstaunlich, dass die Kosten-Perspektive der wissenschaftlichen Bewertung von Psychotherapie noch recht neu ist. Die Klinische Psychologie kann davon profitieren, diese Dimension (neben den beachtlichen Erkenntnisfortschritten in bezug auf Klassifikation, Ätiologie, Verlaufsforschung und Behandlungsverfahren) mehr herauszustellen. (Anlage: Cost-Benefit-Calculator.htm; 8,97 KB -- Nutzung: Referat Informationsvermittlung der SLUB)
246

Individually tailored internet-based cognitive behavioural therapy for anxiety disorders / Skräddarsydd internetförmedlad kognitiv beteendeterapi för ångestproblematik

Bergman Nordgren, Lise January 2013 (has links)
Fear is an innate emotion and an adaptive response to provide protection from potential harm. When fear is excessive and out of proportion in relation to the confronted situation, it can lead to the development of an anxiety disorder. Many individuals feel anxious at some point, but not all experience clinical anxiety or meet the diagnostic criteria of an anxiety disorder. Still, anxiety disorders are the most prevalent form of psychiatric disorder in the general population. More often than not people suffering from one anxiety disorder also present other psychiatric conditions. As of today, cognitive and behavioural treatments have been tested and found to positively affect anxiety disorders, making them the treatment of choice. Nevertheless, many patients do not seek or receive adequate treatment. One common critique of the research trials from which the recommendations for treatments stem is the use of a single protocol targeting only one diagnosis. This is because many people suffer from comorbidities. Another problem connected to the recommendation that cognitive behavioural therapy (CBT) should be the treatment of choice for anxiety disorders is the lack of therapists with adequate training. One possible way of dealing both with the shortcoming of therapists and making CBT more accessible is the use of the Internet. Internet-based CBT (ICBT) has been tested in numerous trials during the last 15 years, showing positive outcomes for a large variety of disorders. Many ICBT trials also make use of a single protocol. Another way of dealing with comorbidities might be to tailor the treatment to let characteristics and preferences of the patient guide the design of the protocol. Little is known about possible effects of tailoring the ICBT, the effects of therapeutic relationships in ICBT, and the effectiveness and cost-effectiveness of these treatments. This thesis is based on three studies on two separate randomized controlled trials (RCTs) using the same set of modules accessible for the tailored protocol. Study I was an RCT investigating treatment effects up to two-year after completion, showing favourable outcomes of the treatment in a self-recruited sample at all measure points. Study II was a secondary analysis exploring possible relations between working alliance and treatment outcome for participants in the treatment group recruited for Study I indicating that working alliance predict outcome in this tailored treatment. The second RCT was an effectiveness trial (Study III) analysing treatment effects and cost-effectiveness of the treatment up to one year post treatment in a primary-care population. This study showed positive treatment effects both regarding symptom reduction and cost-effectiveness, and that effects were sustained at one year post treatment. Conclusions drawn from these studies are that individually tailored ICBT seems to be a feasible approach for patients with anxiety disorders regardless of comorbidities, and a responsible choice in terms of societal costs. / Rädsla är en medfödd känsla och en adaptiv respons för att skydda organismen från potentiell skada. När rädslan blir överdriven och oproportionerlig i relation till den konfronterade situationen, kan det leda till utvecklandet av ångestsyndrom. Många personer upplever någon gång ångest, men inte alla upplever klinisk ångest eller uppfyller de diagnostiska kriterierna för något ångestsyndrom. Trots detta är ångest det vanligaste psykiatriska tillståndet i befolkningen i stort och oftast uppfyller personer som lider av ett ångestsyndrom även andra  psykiatriska tillstånd. Till dags dato har både kognitiva och beteendeinriktade behandlingar testats och visat sig verksamma vid ångestproblem, vilket gjort dem till de behandlingar som rekommenderas för dessa tillstånd. Trots god effekt av behandling söker många patienter ändå inte hjälp, alternativt erhåller inte adekvat behandling. En vanlig kritik mot den forskning från vilka behandlingsrekommendationerna för ångestsyndrom stammar är att många använt en manual eller ett protokoll som riktar sig mot bara en diagnos. Detta på grund av den stora komorbiditeten. Ett annat problem kopplat till rekommendationerna att kognitiv beteendeterapi (KBT) ska vara förstahandsval vid behandling av ångest är bristen på behandlare med adekvat utbildning. Ett möjligt sätt att göra KBT mer tillgängligt är att använda Internet. Internet- förmedlad KBT (IKBT) har prövats i ett stort antal studier de senaste 15 åren dessa har visat positiva resultat vid ett stort antal psykiatriska tillstånd. Flertalet av dessa studier har dock använt ett enda behandlingsprotokoll. En annan möjlighet att hantera komorbiditet kan vara att skräddarsy behandlingen för att låta patientens egenskaper och preferenser vara med och styra utformningen av behandlingsprotokollet. Möjliga effekter av att skräddarsy IKBT är relativt lite undersökt, likaså effekterna av terapeutiska relationer i IKBT samt klinisk effektivitet och kostnadseffektiviteten för dessa behandlingar. Denna avhandling bygger på tre studier från två randomiserade kontrollerade studier med samma uppsättning av moduler tillgängliga för att skräddarsy behandlingsprotokollen. I Studie I undersöktes behandlingseffekter upp till två år efter avslutad behandling i en självrekryterad grupp patienter. Studie II var en sekundäranalys av behandlingsgruppen från Studie I där eventuella samband mellan arbetsallians och behandlingsresultat undersöktes. Den andra randomiserade kontrollerade studien var en prövning av huruvida denna behandling var effektiv för en klinisk population (Studie III) rekryterad via primärvården. Förutom behandlingseffekter undersöktes även kostnadseffektiviteten upp till ett år efter behandlingsavslut. De slutsatser som dras utifrån dessa studier är att skräddarsydd IKBT verkar vara en framkomlig väg för patienter med ångest oavsett komorbiditet, att arbetsalliansen kan vara en faktor som påverkar utfallet, samt att det är ett ansvarsfullt val vad gäller samhälleliga kostnader.
247

Die Stellung der Agoraphobie in modernen diagnostischen Klassifikationssystemen: Beitrag zu einer nosologischen Kontroverse / The position of agoraphobia in modern diagnostic classification systems: Contribution to a nosological controverse

Nocon, Agnes 22 July 2010 (has links) (PDF)
Hintergrund: Seit Einführung des DSM-III-R wird die Frage, ob Agoraphobie eine Komplikation der Panikstörung ist oder eine eigenständige Diagnose darstellt, und deshalb gleichberechtigt mit der Sozialen und Spezifischen Phobie der Gruppe der Phobien zugeordnet werden sollte, kontrovers diskutiert. Die zwei Positionen in dieser Kontroverse finden ihren Ausdruck im unterschiedlichen Gebrauch hierarchischer Regeln in den gegenwärtig gebräuchlichen Klassifikationssystemen für psychische Störungen, dem Diagnostic and Statistical Manual of Mental Disorders (DSM) und der International Classification of Diseases (ICD). Die empirischen Belege für die Validität solcher hierarchischer Regeln sind allerdings bisher unbefriedigend. Ziel der vorliegenden Arbeit ist es deshalb, ohne Berücksichtigung der gültigen Hierarchieregeln das natürliche Auftreten von Agoraphobie und Panikstörung zu untersuchen und damit einen Beitrag zum Fortschritt in der oben genannten Kontroverse zu leisten. Methoden: Die Analysen der vorliegenden Arbeit beruhen auf Daten der Early Developmental Stages of Psychopathology (EDSP) Studie. Bei der EDSP handelt es sich um eine prospektiv-longitudinale Studie an einer bevölkerungsrepräsentativen Kohorte von 3021 Jugendlichen und jungen Erwachsenen im Alter von 14 bis 24 Jahren aus München und Umgebung. Die Studienteilnehmer wurden in einem 10-Jahres-Follow-up mit bis zu vier Erhebungszeitpunkten mit der computerisierten Version des Münchener Composite International Diagnostic Interview (DIA-X/M-CIDI) untersucht. Das M-CIDI gestattet es, Panik- und Agoraphobiesyndrome unabhängig von hierarchischen Regeln zu erheben. Risiko- und Vulnerabilitätsfaktoren wurden anhand von Fragebögen erhoben. Die Studie umfasst darüber hinaus zwei familiengenetische Untersuchungen, in deren Rahmen auch die Eltern der Studienprobanden interviewt wurden. Die direkten Elterninterviews wurden durch Informationen der Studienprobanden über ihre Eltern ergänzt. Ergebnisse: Studie 1: Agoraphobia and Panic: Prospective-longitudinal Relations Suggest a Rethinking of Diagnostic Concepts Die Lifetimeinzidenz bis zum Alter von 34 Jahren betrug 9.4% für Panikattacken, 3.4% für Panikstörung (mit und ohne Agoraphobie) und 5.3% für Agoraphobie. Unter den Personen mit Agoraphobie berichteten 51% keine lifetime Panikattacken. Die Inzidenzmuster der drei Syndrome unterschieden sich bezüglich Erstauftrittsalter, Risikoverlauf und Geschlechtseffekten. Zeitlich vorausgehende Panikattacken und Panikstörung waren assoziiert mit einem Risiko für zeitlich nachfolgende Agoraphobie (Panikattacken: OR=26.7, 95% KI=17.2-41.4; Panikstörung: OR=62.5, 95% KI=38.5-101.2). In streng prospektiven Analysen waren Panikattacken/Panikstörung zur Baseline mit Panikattacken/Panikstörung im Follow-up assoziiert und Agoraphobie zur Baseline mit Agoraphobie im Follow-up. Panikattacken, Panikstörung und Agoraphobie zur Baseline hatten niedrige Remissionsraten (0-23%). Alle diagnostischer Gruppen waren bis auf Panikstörung ohne Agoraphobie mit anderen Angststörungen im Follow-up assoziiert. Panikstörung mit Agoraphobie und Agoraphobie mit Panikattacken zur Baseline zeigten höhere Assoziationen mit Komplikationen wie Beeinträchtigung, Komorbidität und Hilfesuchverhalten als Panikstörung ohne Agoraphobie und Agoraphobie ohne Panikattacken. Personen mit Panikattacken/Panikstörung suchten häufiger ärztliche Hilfe als Personen mit Agoraphobie ohne Panikattacken. Besonders ausgeprägt war Hilfesuchverhalten bei Personen mit Panikstörung mit Agoraphobie. Studie 2: Differential Familial Liability of Panic Disorder and Agoraphobia Panikattacken, Panikstörung und Agoraphobie der Eltern waren assoziiert mit denselben Syndromen der Kinder. Bei separater Untersuchung der Störungen wurde für Agoraphobie ohne Panikstörung keine Assoziation zwischen Eltern und Kindern beobachtet. Elterliche Panikstörung ohne Agoraphobie war nicht mit Panikstörung ohne Agoraphobie bei den Kindern, aber mit Panikstörung mit Agoraphobie (OR=3.9; 95% KI=1.6-9.4) assoziiert. Panikstörung mit Agoraphobie der Eltern war mit Agoraphobie ohne Panikstörung (OR=3.3; 95% KI=1.01-11.1) und mit Panikstörung ohne/mit Agoraphobie bei den Kindern assoziiert (ohne Agoraphobie: OR=4.2; 95% KI=1.2-13.7; mit Agoraphobie: OR=4.9; 95% KI=1.8-12.5). Bei Kontrolle nach anderen Angststörungen blieb nur die Assoziation von Panikstörung mit Agoraphobie bei Eltern und Kindern stabil. Es fanden sich keine Hinweise auf Assoziationen zwischen Panikstörung oder Agoraphobie der Eltern mit einem früheren Erstauftrittsalter der kindlichen Störung. Studie 3: Pathways into panic and phobias Der Komorbidität von Panikstörung, Agoraphobie und Spezifischen Phobien lag eine Vier-Klassen-Struktur zugrunde. Die Klassen konnten beschrieben werden als „sehr niedriges Risiko für Angststörungen“, „niedriges Risiko für Spezifische Phobien“, „moderates Risiko für Agoraphobie und Panikstörung“ und „hohes Risiko für Angststörungen“. Die letztgenannte Klasse zeichnete sich vor allem durch das Vorliegen von Agoraphobie und dem Situativen Subtypus der Spezifischen Phobie aus. Die drei letztgenannten Risikoklassen waren assoziiert mit weiblichem Geschlecht, Behavioral Inhibition, Harm Avoidance, überbehütendem und abweisendem Elternverhalten, elterlichen Angst- und depressiven Störungen, sowie Trennungs- und traumatischen Erlebnissen in der Kindheit. Die Klasse „hohes Risiko für Angststörungen“ war assoziiert mit elterlicher Spezifischer Phobie (OR=5.0, 95% KI=1.9-12.8) und postnatalen Komplikationen (OR=7.4; 95% KI=2.4-22.9). Sie unterschied sich darin von allen anderen Risikogruppen. Die Klasse „moderates Risiko für Agoraphobie und Panikstörung“ war assoziiert mit Trennungsangst in der Kindheit (OR=6.3; 95% KI=2.0-19.8), einem emotional kühlen elterlichen Erziehungsstil (OR=0.7; 95% KI=0.6-0.9) und einer geringen Wahrscheinlichkeit für postnatale Komplikationen (OR=0.3; 95% KI=0.1-0.9). Schlussfolgerungen: Unterschiede hinsichtlich des Inzidenzmusters, des Verlaufs und der Korrelate zwischen Panik- und Agoraphobiesyndromen zeigen, dass Agoraphobie getrennt von Paniksyndromen existiert und eine klinisch relevante Störung darstellt. Dabei hatte die Hälfte der Personen mit Agoraphobie keine Panikattacke erlebt und bliebe gemäß DSM-Kriterien undiagnostiziert. Ergebnisse der Familienstudie zeigen, dass Befunde zur familiären Aggregation von Panikstörung und Agoraphobie bisher von angewandten hierarchischen Diagnoseregeln abhängig waren. Ohne Anwendung hierarchischer Kriterien aggregiert Agoraphobie ohne Panikstörung nicht in Familien und die familiäre Aggregation von Panikstörung hängt davon ab, ob bei den Kindern komorbide Agoraphobie oder andere Angststörungen vorliegen. Die Ergebnisse der Latent Class Analysen lassen vermuten, dass Panikstörung, Agoraphobie und Spezifische Phobien sich im Rahmen von Vulnerabilitätsklassen entwickeln, auf zwei pathogene Mechanismen der Agoraphobie hinweisen: Agoraphobie kann sich entweder in naher Verwandtschaft zur Panikstörung, oder zum Situativen Subtypus der Spezifischen Phobie entwickeln. Spezifische Zusammenhänge dieser Risikoklassen mit untersuchten Vulnerabilitätsfaktoren stützen die Hypothese einer unterschiedlichen Ätiopathogenese der Agoraphobie. Zusammenfassend zeigen die vorliegenden Daten, dass Panikattacken und Panikstörung weder eine notwendige noch eine hinreichende Bedingung für Agoraphobie sind, und die derzeit gültige Klassifikation die Untersuchung der Agoraphobie behindert. Die aktuell in Arbeit befindliche Revision des DSM sollte im Sinne einer beschreibenden, durch empirische Daten gestützten Diagnostik das Konzept der Agoraphobie überarbeiten und von einer Diagnostik im Sinne einer nosologischen Kontroverse abrücken.
248

Τεχνολογία γνώσης πλαισίου και μοντελοποίηση χρηστών σε διάχυτα συστήματα

Παναγιωτακόπουλος, Θεόδωρος 21 December 2011 (has links)
Σήμερα, βρισκόμαστε ήδη στο στάδιο μετάβασης από τις παραδοσιακές επιτραπέζιες υπολογιστικές τεχνολογίες στα διάχυτα (ubiquitous) υπολογιστικά περιβάλλοντα που θα μας υποστηρίζουν σχεδόν σε κάθε καθημερινή μας λειτουργία ή δραστηριότητα. Παράλληλα, υπάρχει μία αυξανόμενη τάση για τοποθέτηση του χρήστη στο κέντρο των υπηρεσιών. Αυτό σημαίνει ότι οι υπηρεσίες θα προσαρμόζονται με βάση το στενό και ευρύτερο περιβάλλον διαβίωσης (context), τις ανάγκες και τις προτιμήσεις των χρηστών. Δύο από τις βασικότερες έννοιες στις οποίες βασίζεται η προσφορά διάχυτων εξατομικευμένων υπηρεσιών είναι η γνώση πλαισίου (context awareness) και η μοντελοποίηση χρηστών (user modeling). Η έλευση του διάχυτου υπολογισμού και η χρησιμοποίηση της διάχυτης μοντελοποίησης χρηστών (ubiquitous user modeling) έχει δημιουργήσει νέες προσδοκίες και προκλήσεις για την παροχή εξατομικευμένων υπηρεσιών σε πολλούς τομείς εφαρμογών μεταξύ των οποίων είναι και ο τομέας της υγείας. Η ιατρική αντιμετώπιση αλλάζει πλέον κατεύθυνση και γίνεται προστατευτική, προληπτική και εύκολα προσεγγίσιμη (π.χ. στη δουλειά, στο σπίτι, κλπ.), συνοδευόμενη από συνεχή και εμμένουσα παροχή υψηλής ποιότητας εξατομικευμένης ιατρικής συμβουλής και υποστήριξης. Οι σύγχρονες ιατρικές υπηρεσίες αναμένονται να είναι διαθέσιμες κάθε στιγμή, 7 ημέρες την εβδομάδα και να παρέχονται με έναν εξατομικευμένο τρόπο ώστε να απευθύνονται στις ιδιαίτερες ανάγκες και απαιτήσεις κάθε ατόμου. Η παρούσα διατριβή πραγματεύεται μία μεθοδολογία παροχής διάχυτων υπηρεσιών σε εξελιγμένα τηλεπικοινωνιακά δίκτυα που συνδυάζει τη γνώση πλαισίου, τη μοντελοποίηση χρηστών και τα κοινωνικά δίκτυα (social networks). Η μεθοδολογία αυτή εφαρμόστηκε στον ιατρικό χώρο και ειδικότερα στις διαταραχές άγχους. Πιο συγκεκριμένα, στη διατριβή καθορίστηκαν πλήρως οι παράμετροι πλαισίου που σχετίζονται άμεσα με τις διαταραχές άγχους και προτάθηκε ένα μοντέλο πλαισίου που βασίζεται σε οντολογίες. Επίσης, μελετήθηκε η δομή και οι τεχνικές κατασκευής και ανανέωσης των μοντέλων χρηστών, ενώ μελετήθηκε η χρήση των κοινωνικών δικτύων για την παροχή ιατρικής φροντίδας και οι ρόλοι των μελών τους στις διαταραχές άγχους. Τέλος, προτάθηκε η αρχιτεκτονική ενός συστήματος γνώσης πλαισίου που ενσωματώνει τις ανωτέρω τεχνολογίες, τμήμα του οποίου αναπτύχθηκε, υλοποιήθηκε και αξιολογήθηκε από επαγγελματίες ιατρούς. Κατά την εφαρμογή της παραπάνω μεθοδολογίας στις διαταραχές άγχους αναπτύχθηκε η εφαρμογή PerMed που αποτελεί ένα εργαλείο αρχειοθέτησης και επεξεργασίας των προσωπικών πληροφοριών των ασθενών και τέσσερις υπηρεσίες που στοχεύουν στην υποστήριξη της θεραπείας των διαταραχών άγχους. Οι τρεις εστιάζουν στην ανακάλυψη πιθανών συσχετίσεων στα δεδομένα πλαισίου, ενώ η τέταρτη στοχεύει στην πρόβλεψη του άγχους που θα παρουσιάσει ένας ασθενής σε ένα δεδομένο πλαίσιο. Τα σχόλια που λάβαμε από επαγγελματίες ψυχιάτρους είναι αρκετά ενθαρρυντικά και ευελπιστούμε ότι η προτεινόμενη προσέγγιση θα αποτελέσει ένα ισχυρό εργαλείο υποστήριξης της θεραπείας των διαταραχών άγχους. / Today, we are already on the transition from the traditional desktop-based computing technologies towards ubiquitous computing environments that will enfold us in almost all our daily situations and activities. Simultaneously, there exists an increased tendency of putting the user into the center of service delivery. This means that the services in the ubiquitous environments should be adapted to the context, the needs and the preferences of users. Two of the key-concepts, based on which the delivery of ubiquitous personalized services is realized, are context-awareness and user modeling. The emergence of ubiquitous computing and ubiquitous user modeling has created new expectations and challenges for the delivery of personalized services in a considerable amount of application domains, among which is the healthcare domain. Healthcare provision changes direction becoming protective, proactive and more reachable (e.g. at home or at work), accompanied by continuous and persistent provision of personalized high-quality health advice and assistance. Modern healthcare services are expected to be available around the clock, seven days a week and delivered in a personalized manner addressing the specific needs and preferences of each individual. The present dissertation presents a methodology of providing ubiquitous services at advanced telecommunication networks, which combines context-awareness, user modeling and social networks. This methodology was implemented in the healthcare domain and more specifically in anxiety disorders. In particular, in this dissertation, the contextual aspects that are directly associated with anxiety disorders were defined and an ontology-based context model was proposed. In addition, the user models’ structure was determined and the techniques for the processing of their content were developed. Furthermore, the use of social networks in anxiety disorders and the role of their members were studied. Finally, the architecture of a context-aware system that integrates all the above technologies was proposed, a part of which was developed, implemented and evaluated by professional psychiatrists. During the implementation of the proposed methodology in anxiety disorders, the PerMed application that provides medical experts with a tool for archiving and processing the patient’s personal data and four treatment supportive services were developed. The three of them focus on the discovery of possible associations between the patient’s contextual data and the last service aims at predicting the stress level a patient might suffer from, in a given context. The feedback received from expertized psychiatrists was very encouraging and we hope that the proposed approach will constitute a powerful treatment supportive tool for anxiety disorders.
249

Estudo da influência da cafeína sobre o efeito antidepressivo da privação de sono em pacientes deprimidos

Schwartzhaupt, Alexandre Willi January 2008 (has links)
Introdução: A privação de sono (PdS) tem sido utilizada como um estratégia alternativa para o tratamento do Transtorno Depressivo Maior (TDM), contudo sua eficácia e efetividade carecem de estudos homogêneos e de bom delinemento para dar um grau de evidência científica para seu uso na prática diária. Assim sendo, desde a primeira publicação, em 1971, num relato de caso de um paciente com TDM grave tipo melancólico, por Plug e Tölle, o mesmo estava assintomático no dia seguinte à privação total de sono. Contudo, na noite seguinte de sono seus sintomas depressivos retornaram. Nestes quase 40 anos desde esta publicação houve dezenas de estudos em sua maioria relatos de caso, série de casos ou até estudos abertos só que misturando pacientes com TDM com Depressão Bipolar sem mesmo distinguir se tipo I ou II. A cafeína com seu efeito estimulador poderia ser uma alternativa para facilitar a privação de sono. No entanto, não há dados sobre o sua potencial influência no efeito antidepressivo da PdS. O objetivo deste estudo é avaliar o efeito da cafeína na PdS em pacientes deprimidos unipolares moderados a graves não psicóticos. Métodos: Ensaio Clínico randomizado, duplo cego, cruzado, comparando cafeína contra placebo em pacientes deprimidos moderados a graves submetidos à privação total de sono (PdS). Os pacientes foram avaliados por itens da escala de Lader, HAMD- 6 itens, CGI Severidade e Melhora Global. Resultados: Foram avaliados 20 pacientes. Os pacientes que usaram cafeína mantiveram o mesmo escore de energia pré e pós-privação de sono (item energético-letárgico da escala de Lader) enquanto os do grupo placebo diminuíram o escore de energia pós-privação de sono. (p = 0,0045). Não houve diferença entre o grupo cafeína e placebo nos demais itens da escala de Lader. Conclusão: O uso combinado de cafeína e PdS pode ser uma estratégia útil para manter os pacientes mais acordados sem o prejuízo do cansaço da PdS em pacientes ambulatoriais deprimidos. Contudo, mais estudos envolvendo pacientes que tenham 10 respondido à PdS são necessários para verificar se a cafeína também não interfere nos resultados deste grupo. / Introduction: Sleep deprivation (SD) has been used as an alternative approach to treat major depressive disorder (MDD), however the efficacy and the effectiveness needs studies with homogeneity and better delineament to strengthen the evidence based medicine to the use in the practical daily use. Besides, since the 1° puplication in 1971 of a case report, by Plug and Tölle, in that one patient with severe melancholic depressive disorder achieved remission in the next day after a total sleep deprivation. However his depressive sintomtology was back after the next night of sleep. Since this almost 40 years, a lot of papers were puplished, and the majority where case report, case reports and open trials with patients with MDD, bipolar depression without make difference between tipe I or II. Caffeine, due to its stimulating effect, could be an alternative to promote sleep deprivation. However, there are no data about its potential influence on the antidepressive effect of SD. The objective of this study is to assess the effect of caffeine on SD in non-psychotic patients with moderate to severe unipolar depression. Methods: Randomized, double-blind, crossover clinical trial comparing caffeine and placebo in moderate to severe depressed patients who underwent total sleep deprivation (SD). The patients were assessed with items of the Bond-Lader Scale, the 6-item Hamilton Depression Rating Scale (HAMD-6), and the Clinical Global Impression (CGI)-Severity/Improvement. Results: Twenty patients participated in this study. The patients who consumed caffeine presented the same score of energy before and after sleep deprivation (lethargicenergetic item of the Bond-Lader scale), while the patients in the placebo group had a reduced score of energy after sleep deprivation (p = 0.0045). There was no difference between the caffeine and placebo groups in the other items of the Bond-Lader scale. Conclusion: The combined use of caffeine and SD can be a useful strategy to keep the 12 patient awake without impairing the effect of SD on depressed outpatients. However, further studies involving patients who have responded to SD are needed in order to verify if caffeine also does not interfere with the results in this group.
250

Estudo da influência da cafeína sobre o efeito antidepressivo da privação de sono em pacientes deprimidos

Schwartzhaupt, Alexandre Willi January 2008 (has links)
Introdução: A privação de sono (PdS) tem sido utilizada como um estratégia alternativa para o tratamento do Transtorno Depressivo Maior (TDM), contudo sua eficácia e efetividade carecem de estudos homogêneos e de bom delinemento para dar um grau de evidência científica para seu uso na prática diária. Assim sendo, desde a primeira publicação, em 1971, num relato de caso de um paciente com TDM grave tipo melancólico, por Plug e Tölle, o mesmo estava assintomático no dia seguinte à privação total de sono. Contudo, na noite seguinte de sono seus sintomas depressivos retornaram. Nestes quase 40 anos desde esta publicação houve dezenas de estudos em sua maioria relatos de caso, série de casos ou até estudos abertos só que misturando pacientes com TDM com Depressão Bipolar sem mesmo distinguir se tipo I ou II. A cafeína com seu efeito estimulador poderia ser uma alternativa para facilitar a privação de sono. No entanto, não há dados sobre o sua potencial influência no efeito antidepressivo da PdS. O objetivo deste estudo é avaliar o efeito da cafeína na PdS em pacientes deprimidos unipolares moderados a graves não psicóticos. Métodos: Ensaio Clínico randomizado, duplo cego, cruzado, comparando cafeína contra placebo em pacientes deprimidos moderados a graves submetidos à privação total de sono (PdS). Os pacientes foram avaliados por itens da escala de Lader, HAMD- 6 itens, CGI Severidade e Melhora Global. Resultados: Foram avaliados 20 pacientes. Os pacientes que usaram cafeína mantiveram o mesmo escore de energia pré e pós-privação de sono (item energético-letárgico da escala de Lader) enquanto os do grupo placebo diminuíram o escore de energia pós-privação de sono. (p = 0,0045). Não houve diferença entre o grupo cafeína e placebo nos demais itens da escala de Lader. Conclusão: O uso combinado de cafeína e PdS pode ser uma estratégia útil para manter os pacientes mais acordados sem o prejuízo do cansaço da PdS em pacientes ambulatoriais deprimidos. Contudo, mais estudos envolvendo pacientes que tenham 10 respondido à PdS são necessários para verificar se a cafeína também não interfere nos resultados deste grupo. / Introduction: Sleep deprivation (SD) has been used as an alternative approach to treat major depressive disorder (MDD), however the efficacy and the effectiveness needs studies with homogeneity and better delineament to strengthen the evidence based medicine to the use in the practical daily use. Besides, since the 1° puplication in 1971 of a case report, by Plug and Tölle, in that one patient with severe melancholic depressive disorder achieved remission in the next day after a total sleep deprivation. However his depressive sintomtology was back after the next night of sleep. Since this almost 40 years, a lot of papers were puplished, and the majority where case report, case reports and open trials with patients with MDD, bipolar depression without make difference between tipe I or II. Caffeine, due to its stimulating effect, could be an alternative to promote sleep deprivation. However, there are no data about its potential influence on the antidepressive effect of SD. The objective of this study is to assess the effect of caffeine on SD in non-psychotic patients with moderate to severe unipolar depression. Methods: Randomized, double-blind, crossover clinical trial comparing caffeine and placebo in moderate to severe depressed patients who underwent total sleep deprivation (SD). The patients were assessed with items of the Bond-Lader Scale, the 6-item Hamilton Depression Rating Scale (HAMD-6), and the Clinical Global Impression (CGI)-Severity/Improvement. Results: Twenty patients participated in this study. The patients who consumed caffeine presented the same score of energy before and after sleep deprivation (lethargicenergetic item of the Bond-Lader scale), while the patients in the placebo group had a reduced score of energy after sleep deprivation (p = 0.0045). There was no difference between the caffeine and placebo groups in the other items of the Bond-Lader scale. Conclusion: The combined use of caffeine and SD can be a useful strategy to keep the 12 patient awake without impairing the effect of SD on depressed outpatients. However, further studies involving patients who have responded to SD are needed in order to verify if caffeine also does not interfere with the results in this group.

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