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Fatores de risco para mortalidade precoce : Estudos de trajetórias e preditores no primeiro episódio psicótico
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As perturbações psicóticas são, pelo seu quadro clínico e impacto na vida dos doentes, as mais graves perturbações em Psiquiatria, com uma prevalência de cerca de 3%. Estudos demonstram que as taxas de mortalidade nestes doentes estão aumentadas 2 a 3 vezes em relação à população geral, vivendo os doentes psicóticos entre 10 a 25 menos anos em comparação com a população geral. O risco de mortalidade nas perturbações psicóticas é particularmente elevado nos primeiros anos de perturbação. As principais causas deste excesso de mortalidade incluem as doenças cardiovasculares, nomeadamente doença isquémica coronária, e o suicídio. Este trabalho investigou a prevalência, evolução e possíveis fatores preditores do comportamento suicida e síndroma metabólica, reconhecidos fatores de risco para suicídio e doença cardiovascular respetivamente, nos 12 meses seguintes a um primeiro episódio psicótico. Trata-se de um estudo longitudinal, que incluiu doentes com primeiro episódio psicótico afetivo e não afetivo de duas equipas de intervenção precoce na psicose na área metropolitana de Lisboa, Portugal. Os doentes foram submetidos a uma avaliação compreensiva que incluiu dados socio-demográficos e clínicos, em dois momentos distintos: uma avaliação realizada na baseline, logo que existiam condições clínicas para esta durante o primeiro episódio psicótico, e uma segunda avaliação 12 meses após a primeira. O comportamento suicida foi investigado por um questionário sobre ideação suicida, plano suicida e tentativa de suicídio. A síndroma metabólica foi avaliada usando os critérios da definição modificada da National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III).
Os resultados mostraram uma prevalência de comportamento suicida de 25,4% na avaliação baseline, com uma significativa redução para 13,3% (p=0,035) na avaliação a 12 meses. A análise logística binária multivariada mostrou que a história prévia de comportamento suicida e diagnóstico de depressão no primeiro episódio psicótico foram preditores de comportamento suicida no momento da avaliação baseline, e a história prévia de comportamento suicida e baixos níveis de colesterol total na baseline mostraram ser preditores de comportamento suicida 12 meses após o primeiro episódio psicótico. Em relação à prevalência da síndroma metabólica encontrou-se um aumento de 6,7% na avaliação baseline para 11,7% na avaliação a 12 meses (p=0,250) As prevalências de valores não normais de perímetro abdominal (p=0,039), triglicéridos (p=0.040) e HDL (p=0,019) aumentaram significativamente da avaliação baseline para a avaliação a 12 meses. Todos os parâmetros metabólicos e antropométricos estudados (triglicéridos, HDL, pressão arterial, perímetro abdominal e glucose em jejum) agravaram durante o período de follow-up, mas apenas de forma estatisticamente significativa o perímetro abdominal, triglicéridos e HDL. Apenas o valor médio do perímetro abdominal foi na avaliação a 12 meses não normal (valor médio: 102,50cm±99,41; valores não normais: homem≥102 cm e mulheres≥88cm). Não se identificaram preditores na baseline para o desenvolvimento de síndroma metabólica na avaliação a 12 meses.
Este trabalho mostrou uma prevalência elevada de comportamento suicida no ano seguinte ao primeiro episódio psicótico, com uma redução durante o período de follow-up, mas ainda com uma taxa significativa aos 12 meses. Os nossos resultados também mostraram valores elevados das alterações metabólicas com rápido agravamento no primeiro ano após o primeiro episódio psicótico, apesar da não existência de significância estatística para a síndroma metabólica. O perímetro abdominal, indicador de obesidade, foi o parâmetro metabólico estudado que mais significativamente aumentou durante os 12 meses de follow-up, parecendo indicar que este é um fator primário da síndroma metabólica, sendo os restantes elementos secundários aquele.
Os nossos resultados mostram que doentes com primeiro episódio psicótico com história prévia de comportamento suicida, depressão e baixos níveis de colesterol total no primeiro episódio psicótico estão em risco particularmente elevado de comportamento suicida, e consequentemente de suicídio, nos 12 meses seguintes ao primeiro episódio psicótico. Este grupo de doentes beneficiará potencialmente de tratamento adequado no sentido da sua proteção e redução do risco de suicídio. Os nossos resultados indicam também que deve existir uma cuidadosa monitorização dos parâmetros metabólicos nos primeiros 12 meses após o primeiro episódio psicótico, aqueles que apresentem critérios de síndroma metabólica, devem ser submetidos a um plano de intervenção sobre os estilos de vida e tratamento. A investigação futura deve procurar replicar os resultados encontrados e ampliar o conhecimento em relação a intervenções que sejam particularmente eficazes neste grupo de doentes com primeiro episódio psicótico e risco elevado de doença cardiovascular e/ou suicídio. Os estudos futuros devem ainda avaliar se estas intervenções têm impacto, como esperado, na redução da mortalidade dos doentes psicóticos, nomeadamente nas fases iniciais destas perturbações.
Psychotic disorders are, for their clinical picture and impact on patients' lives, the most serious disorders in Psychiatry, with a prevalence of around 3%. Studies show that mortality rates in these patients are 2 to 3 times higher than in the general population, with psychotic patients living 10 to 25 years less than the general population. The risk of mortality in psychotic disorders is particularly high in the first years of the disorder. The main causes of this excess of mortality include cardiovascular disease, notably coronary ischaemic disease, and suicide. This study investigated the prevalence, evolution and possible predictors of suicidal behaviour and metabolic syndrome, recognized risk factors for suicide and cardiovascular disease respectively, in the 12 months following a first episode psychosis. This is a longitudinal study, which included patients with affective and non-affective first-episode psychosis from two early psychosis intervention teams in the metropolitan area of Lisbon, Portugal. Patients were submitted to a comprehensive assessment including socio-demographic and clinical data, at two distinct moments: an assessment carried out at baseline, as soon as clinical condition for this assessment existed during the first-episode psychosis, and a second assessment 12 months after the first one. Suicidal behaviour was investigated by a questionnaire on suicide ideation, suicide planning and suicide attempt. Metabolic syndrome was assessed using the criteria of the modified definition of the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III). Results showed a prevalence of suicidal behaviour of 25.4% at baseline assessment, with a significant reduction to 13.3% (p=0.035) at 12 months assessment. The multivariate binary logistic analysis showed that previous history of suicidal behaviour and diagnosis of depression at the first-episode psychosis were predictors of suicidal behaviour at baseline assessment, and previous history of suicidal behaviour and low total cholesterol levels at baseline were predictors of suicidal behaviour 12 months after the first-episode psychosis. The prevalence of metabolic syndrome increased from 6.7% at baseline to 11.7% at 12 months (p=0.250). The prevalence of abdominal circumference (p=0.039), triglyceride (p=0.040) and HDL (p=0.019) non-normal values increased significantly from baseline to 12 months. All metabolic and anthropometric parameters studied (triglycerides, HDL, blood pressure, abdominal circumference and fasting glucose) worsened during the follow-up period, but only abdominal circumference, triglycerides and HDL were statistically significant. Only the mean abdominal circumference value was at the 12-month assessment non-normal (mean value: 102.50cm±99.41; non-normal values: men≥102cm and women≥88cm). No predictors were identified at baseline for the development of metabolic syndrome at 12-month assessment. This work showed a high prevalence of suicidal behaviour in the year following the first-episode psychosis, with a reduction during the follow-up period, but still a significant rate at 12 months. Our results also showed high values of metabolic changes with rapid worsening in the first year after first-episode psychosis despite of non-significance on statistical analysis on metabolic syndrome. Abdominal circumference, an indicator of obesity, was the metabolic parameter studied which increased most significantly during the 12 months of follow-up, seeming to indicate that this is a primary factor of the metabolic syndrome, the other elements being secondary to it. Our results show that first-episode psychosis patients with a previous history of suicidal behaviour, depression and low total cholesterol levels in the first-episode psychosis are at particularly high risk of suicidal behaviour, and consequently of suicide, in the 12 months following the first psychotic episode. This group of patients will potentially benefit from appropriate treatment in order to protect them and reduce their risk of suicide. Our results also indicate that there should be careful monitoring of metabolic parameters in the first 12 months after the first-episode psychosis, those with criteria for metabolic syndrome should undergo a lifestyle and treatment intervention plan. Future research should seek to replicate the results found and expand knowledge regarding interventions that are particularly effective in this group of patients with first-episode psychosis and high risk of cardiovascular disease and/or suicide. Future studies should also assess whether these interventions have an impact, as expected, on reducing mortality in psychotic patients, particularly in the early stages of these disorders.
Psychotic disorders are, for their clinical picture and impact on patients' lives, the most serious disorders in Psychiatry, with a prevalence of around 3%. Studies show that mortality rates in these patients are 2 to 3 times higher than in the general population, with psychotic patients living 10 to 25 years less than the general population. The risk of mortality in psychotic disorders is particularly high in the first years of the disorder. The main causes of this excess of mortality include cardiovascular disease, notably coronary ischaemic disease, and suicide. This study investigated the prevalence, evolution and possible predictors of suicidal behaviour and metabolic syndrome, recognized risk factors for suicide and cardiovascular disease respectively, in the 12 months following a first episode psychosis. This is a longitudinal study, which included patients with affective and non-affective first-episode psychosis from two early psychosis intervention teams in the metropolitan area of Lisbon, Portugal. Patients were submitted to a comprehensive assessment including socio-demographic and clinical data, at two distinct moments: an assessment carried out at baseline, as soon as clinical condition for this assessment existed during the first-episode psychosis, and a second assessment 12 months after the first one. Suicidal behaviour was investigated by a questionnaire on suicide ideation, suicide planning and suicide attempt. Metabolic syndrome was assessed using the criteria of the modified definition of the National Cholesterol Education Program Adult Treatment Panel III (NCEP-ATP III). Results showed a prevalence of suicidal behaviour of 25.4% at baseline assessment, with a significant reduction to 13.3% (p=0.035) at 12 months assessment. The multivariate binary logistic analysis showed that previous history of suicidal behaviour and diagnosis of depression at the first-episode psychosis were predictors of suicidal behaviour at baseline assessment, and previous history of suicidal behaviour and low total cholesterol levels at baseline were predictors of suicidal behaviour 12 months after the first-episode psychosis. The prevalence of metabolic syndrome increased from 6.7% at baseline to 11.7% at 12 months (p=0.250). The prevalence of abdominal circumference (p=0.039), triglyceride (p=0.040) and HDL (p=0.019) non-normal values increased significantly from baseline to 12 months. All metabolic and anthropometric parameters studied (triglycerides, HDL, blood pressure, abdominal circumference and fasting glucose) worsened during the follow-up period, but only abdominal circumference, triglycerides and HDL were statistically significant. Only the mean abdominal circumference value was at the 12-month assessment non-normal (mean value: 102.50cm±99.41; non-normal values: men≥102cm and women≥88cm). No predictors were identified at baseline for the development of metabolic syndrome at 12-month assessment. This work showed a high prevalence of suicidal behaviour in the year following the first-episode psychosis, with a reduction during the follow-up period, but still a significant rate at 12 months. Our results also showed high values of metabolic changes with rapid worsening in the first year after first-episode psychosis despite of non-significance on statistical analysis on metabolic syndrome. Abdominal circumference, an indicator of obesity, was the metabolic parameter studied which increased most significantly during the 12 months of follow-up, seeming to indicate that this is a primary factor of the metabolic syndrome, the other elements being secondary to it. Our results show that first-episode psychosis patients with a previous history of suicidal behaviour, depression and low total cholesterol levels in the first-episode psychosis are at particularly high risk of suicidal behaviour, and consequently of suicide, in the 12 months following the first psychotic episode. This group of patients will potentially benefit from appropriate treatment in order to protect them and reduce their risk of suicide. Our results also indicate that there should be careful monitoring of metabolic parameters in the first 12 months after the first-episode psychosis, those with criteria for metabolic syndrome should undergo a lifestyle and treatment intervention plan. Future research should seek to replicate the results found and expand knowledge regarding interventions that are particularly effective in this group of patients with first-episode psychosis and high risk of cardiovascular disease and/or suicide. Future studies should also assess whether these interventions have an impact, as expected, on reducing mortality in psychotic patients, particularly in the early stages of these disorders.
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Palavras-chave
primeiro episódio psicótico síndroma metabólica comportamento suicida esquizofrenia first-episode psychosis metabolic syndrome suicidal behaviour schizophrenia