Diversas questões ainda estão em aberto no que se refere a um tema tão amplo quanto a saúde mental das mulheres em período de gestação e puerpério. Por mais contraditório que possa parecer, muitas pacientes apresentam tristeza ou ansiedade em vez de alegria nessas fases de suas vidas. Os limites entre o fisiológico e o patológico podem ser estreitos, o que pode gerar dúvidas em obstetras, clínicos ou psiquiatras. Muitas pacientes também sentem-se culpadas, prejudicando a aderência ao tratamento e a aceitação de uma patologia em uma fase que, em tese, deveria ser de alegria. Nas últimas décadas, estudos têm investigado um pouco mais sobre o tema, mas algumas questões ainda estão em debate: os transtornos puerperais poderiam ser uma manifestação de um transtorno prévio não adequadamente tratado? Seriam a gestação ou o puerpério fatores protetores ou de risco para o desencadeamento de transtornos psiquiátricos? As alterações hormonais que ocorrem nesse período poderiam estar envolvidas na sua etiologia? Quais seriam os principais fatores de risco? Em quais situações seria adequado usar psicofármacos como medida de tratamento? Neste artigo, serão abordadas algumas dessas questões, sobre um tema que ainda precisa ser muito investigado para que tenhamos conclusões mais precisas.Palavras-chave: Gestação, puerpério, transtornos psiquiátricos, fatores de risco, tratamento

CONTEXT AND OBJECTIVE: Chronic use of benzodiazepines is frequent in general practice. The aim of this study was to describe the usage pattern and profile of chronic users of diazepam who had been consuming this drug for a minimum of thirty-six months continuously. DESIGN AND SETTING: This was a descriptive study (survey and clinical assessment) at five primary healthcare centers in Campinas, Brazil. METHODS: Psychotropic drug control books revealed 48 eligible patients. Among these, 41 were assessed by means of the Schedule for Clinical Assessment in Neuropsychiatry (SCAN), the Hospital Anxiety and Depression scale (HAD) and a questionnaire on usage pattern. RESULTS: Most patients were women (85.4%). The patients' mean age was 57.6 years, and they were from the social strata C (39%), D (54%) and E (7%). The mean length of diazepam consumption was 10 years. The patients presented a lack of prescription compliance and had made frustrated attempts to stop using the drug. 55.5% said their doctor had never given any guidance on the effects of the drug. According to SCAN, 25 patients (61%) suffered from depressive disorders; only 12 cases of benzodiazepine dependence were detected by this instrument. CONCLUSION: There is a need to improve the detection and treatment of mental disorders, as well as to prevent inappropriate prescription and use of benzodiazepines. Diazepam dependence has distinctive characteristics that make it undetected by SCAN.

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Objective: Ketamine infusion followed by maintenance ECT and medications result in longer remission compared to ketamine infusion followed by maintenance medications alone, as observed in a clinical case. Background: Patients with severe treatment-resistant depression are usually tried on combinations of antidepressant medications, augmentation with other medications, or electroconvulsive therapy (ECT). Recently, Berman et al. and Zarate et al. have reported a rapid antidepressant response after a single ketamine infusion with improvement lasting up to 7 days (Berman RM et al. Antidepressant effects of ketamine in depressed patients. Biol Psychiatry 2000; 47:351Y4; Zarate CA et al. A randomized trial of an N-methyl-D-aspartate antagonist in treatment-resistant major depression. Arch Gen Psychiatry 2006; 63:856Y64).Here, we report the case of a patient who was first treated with ketamine infusion but achieved only 10 days remission with maintenance medication alone. He was treated again with ketamine infusion, and then successfully sustained in remission with medications and ECT in combination. Design/Methods: A 32-year-old male college student with a history of major depressive disorder and OCD features had received multiple adequate antidepressant trials (including clomipramine, fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram, escitalopram, venlafaxine, buproprion, duloxetine). Approximately two years previously he had undergone a course of RUL ECT and bilateral ECT which yielded clinical improvement, but caused unacceptable cognitive side effects. Maintenance antidepressants resulted in partial responses and brief periods of remissions. He was hospitalized following a serious suicidal attempt by overdosing on multiple medications. After he was medically stabilized, he was admitted to inpatient psychiatric unit. He was reluctant to have ECT due to memory problems from his previous ECT. He was willing to receive intravenous ketamine infusion. Informed consent was obtained and the patient was treated with a ketamine infusion of 0.5 mg/kg administered over 40 min. His medications were continued, including duloxetine, paroxetine, alprazolam and ziprasidone. The ketamine infusion resulted in a rapid improvement in his depression. His Beck Depression Inventory (BDI) changed from baseline score of 44 to 14 within 24 hours. He was discharged home after 6 days and continued on the same medications. By day 10 he relapsed, became acutely depressed with suicidal ideations, and again required hospitalization. Repeated ketamine infusion resulted in rapid improvement of depression within 24 hours (BDI score decreased from 40 to 24 in 24 hours and to 18 in 48 hours). This time the patient was willing to start bifrontal ECT. His antidepressant medications were continued and bifrontal ECT was started 3 days postinfusion in attempt to maintain his clinical improvement. He was successfully maintained on twice weekly ECT for 3.5 weeks (total of 7 sessions), followed by once a month ECT for 3 months. During that time BDI ...

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