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A INSUSTENTÁVEL CERTEZA DA MORTE: A EUTANÁSIA E O SOFRIMENTO INVISÍVEL
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O tema matriz do presente estudo aborda questões relativas à necessidade de se preservar a dignidade do homem na terminalidade da vida. Busca-se apresentar breves reflexões acerca do direito de se ter uma morte digna, sob o fundamento da autonomia da vontade como vertente do princípio da dignidade da pessoa humana e base elementar da Bioética. Para tanto, utilizou-se do método dedutivo e da pesquisa bibliográfica, partindo de premissas extraídas do conceito de dignidade do homem, autonomia, moral e ética, para buscar o reconhecimento do direito de morrer dignamente como decorrência do direito constitucional fundamental à vida.
O objetivo deste estudo foi revisar a epidemiologia, a sintomatologia clínica e a classificação dos diversos subtipos de transtornos depressivos, conforme os modernos sistemas de diagnóstico e de pesquisa, e descrever, de forma crítica, sob à luz da Psicanálise, os principais aspectos psicodinâmicos subjacentes. Destacamos, particularmente, os quadros de depressão melancólica e atípica, enfatizando a necessidade do reconhecimento diagnóstico precoce e da compreensão psicanalítica como instrumentos importantes para a intervenção e para o tratamento.
Although clinical trials have documented the importance of identifying individuals with major depression with atypical features, there are fewer epidemiological data. In a prior report, the authors used latent class analysis (LCA) to identify a distinctive atypical depressive subtype; they sought to replicate that finding in the current study.
Using the National Comorbidity Survey data, the authors applied LCA to 14 DSM-III-R major depressive symptoms in the participants' lifetime worst episodes (N=2,836). Validators of class membership included depressive disorder characteristics, syndrome consequences, demography, comorbidity, personality/attitudes, and parental psychiatric history.
The best-fitting LCA solution had six classes. Four were combinations of atypicality and severity: severe atypical, mild atypical, severe typical, and mild typical. Syndrome severity (severe atypical and typical versus mild atypical and typical classes) was associated with a pronounced pattern of more and longer episodes, worse syndrome consequences, increased psychiatric comorbidity, more deviant personality and attitudes, and parental alcohol/drug use disorder. Syndrome atypicality (severe and mild atypical versus severe and mild typical classes) was associated with decreased syndrome consequences, comorbid conduct disorder and social phobia, higher interpersonal dependency and lower self-esteem, and parental alcohol/drug use disorder.
As in prior reports, the atypical subtype of depression can be identified in epidemiological samples and, like typical depression, exists in mild and severe variants. Atypical depressive subtypes were characterized by several distinctive features. However, the correspondence between epidemiologically derived typologies of atypical depression and DSM-IV major depression with atypical features is not yet known.
The purpose of this study was to determine the treatment history and cost of previous treatment among patients with comorbid substance-related disorder and dysthymia, as compared to patients with substance-related disorder only.
Retrospective data were obtained regarding past treatment. Treatment cost was calculated on the basis of the 1996 cost of various treatment modalities. The setting was alcohol-drug programs located within departments of psychiatry in two centers. A total of 642 patients were assessed, of whom 39 had substance-related disorder and dysthymia and 308 had substance-related disorder only (the remaining patients had other comorbid conditions). Data collection instruments included an interview-based questionnaire regarding previous psychiatric and substance abuse treatment. Current cost of treatment in various settings was assessed on the basis of a survey of facilities used by patients in this area.
Patients with substance-related disorder and dysthymia had received more substance-related disorder treatment in 18 of 20 measures. Patients with substance-related disorder and dysthymia used 4.7 times more substance-related disorder treatment dollars than patients with substance-related disorder only, although their demographic characteristics were similar. Past self-help activities and pharmacotherapy were remarkably similar for both groups. Although substance-related disorder treatment differed considerably between the two groups of patients, other types of psychiatric treatment (i.e., non-substance-related treatment) did not differ between the two groups.
Patients with substance-related disorder and dysthymia are referred to (or seek) substance-related disorder treatment more often than patients with substance-related disorder only but are referred to (or seek) non-substance-related psychiatric treatment no more often than patients with substance-related disorder only. The cost of previous substance-related disorder treatment was several times higher for the patients with substance-related disorder and dysthymia.
Many functions have been suggested for low mood or depression, including communicating a need for help, signaling yielding in a hierarchy conflict, fostering disengagement from commitments to unreachable goals, and regulating patterns of investment. A more comprehensive evolutionary explanation may emerge from attempts to identify how the characteristics of low mood increase an organism's ability to cope with the adaptive challenges characteristic of unpropitious situations in which effort to pursue a major goal will likely result in danger, loss, bodily damage, or wasted effort. In such situations, pessimism and lack of motivation may give a fitness advantage by inhibiting certain actions, especially futile or dangerous challenges to dominant figures, actions in the absence of a crucial resource or a viable plan, efforts that would damage the body, and actions that would disrupt a currently unsatisfactory major life enterprise when it might recover or the alternative is likely to be even worse. These hypotheses are consistent with considerable evidence and suggest specific tests.
Although dysthymia, a chronic, low-grade form of depression, has a morbidity rate as high as that of major depression, and increases the risk for major depressive disorder, limited information is available concerning the etiology of this illness. In the present report we review literature concerning the biological and characterological features of dysthymia, the effectiveness of antidepressant treatments, the influence of stressors in the precipitation and maintenance of the disorder, and both quality of life and psychosocial correlates of the illness. We also provisionally suggest that dysthymia may stem from disturbances of neuroendocrine and neurotransmitter functioning (eg, corticotropin releasing hormone and arginine vasopressin within the hypothalamus, or alternatively monoamine variations within several extrahypothalamic sites), and may also involve cytokine activation. The central disturbances may reflect phenotypic variations of neuroendocrine processes or sensitization of such mechanisms. It is suggested that chronic stressor experiences or stressors encountered early in life lead to the phenotypic neurochemical alterations, which then favor the development of the dysthymic state. Owing to the persistence of the neurochemical disturbances, vulnerability to double depression is increased, and in this instance treatment with antidepressants may attenuate the symptoms of major depression but not those of the basal dysthymic state. Moreover, the residual features of depression following treatment may be indicative of underlying neurochemical disturbances, and may also serve to increase the probability of illness recurrence or relapse.
Traducción de: L'homme et la mort Edgar Morin, aborda el problema antropológico de la muerte partiendo de la biología, las concepciones que de ella tuvo el hombre primitivo, sus cristalizaciones históricas y esta crisis de la muerte actual, que la relaciona con la crisis de la individualidad contemporánea.
Divulgação dos SUMÁRIOS das obras recentemente incorporadas ao acervo da Biblioteca Ministro Oscar Saraiva do STJ. Em respeito à lei de Direitos Autorais, não disponibilizamos a obra na íntegra.
This paper reviews current evidence in support of dysthymia as a sub-affective disorder that precedes major affective episodes, often by more than a decade. In cases beginning in childhood or adolescence, dysthymia is associated with high familial rates of mood disorders, and a recurrent pattern of superimposed major depression. At least two trait-like markers, sleep electro-encephalographic and thyroid axis abnormalities-similar to those in major affective disorder-have been reported. These data indicate a common pathophysiological substrate for both dysthymia and major depressive illness. All classes of antidepressants-most recently the serotonin re-uptake and the reversible MAO inhibitors-have been shown to be effective. Dysthymia was fairly recently included in the US(DSM) and WHO(ICD) classifications of mental disorders, because it characterises a prevalent clinical presentation of depression in both psychiatric and general medical settings. Patients given this diagnosis, instead of presenting with acute or full-blown episodes, often complain of low-grade chronic affective malaise for as long as they remember, yet without clinically observable signs of depression. As a result, questions have been raised about its validity, but from fundamentally opposite positions: (i) Is dysthymia better conceptualised as a personality (or neurotic) rather than mood disorder? (ii) Can dysthymia be distinguished from major depressive illness? This paper examines these and related questions along both clinical and external validating strategies, and in particular, the more recent accumulated evidence in support of the utility of the concept of dysthymia.
While the sex difference in prevalence rates of unipolar depression is well established, few studies have examined gender differences in clinical features of depression. Even less is known about gender differences in chronic forms of depression.
235 male and 400 female outpatients with DSM-III-R chronic major depression or double depression (i.e., major depression superimposed on dysthymia) were administered an extensive battery of clinician-rated and self-report measures.
Women were less likely to be married and had a younger age at onset and greater family history of affective disorder compared to men. Symptom profile was similar in men and women, with the exception of more sleep changes, psychomotor retardation and anxiety/somatization in women. Women reported greater severity of illness and were more likely to have received previous treatment for depression with medications and/or psychotherapy. Greater functional impairment was noted by women in the area of marital adjustment, while men showed more work impairment.
Since our population consisted of patients enrolling in a clinical trial, study exclusion criteria may have affected gender-related differences found.
Chronicity of depression appears to affect women more seriously than men, as manifested by an earlier age of onset, greater family history of affective disorders, greater symptom reporting, poorer social adjustment and poorer quality of life. These findings represent the largest study to date of gender differences in a population with chronic depressive conditions.
Chronic depression represents an important public health concern for women. It is underrecognized and undertreated and is associated with significant functional impairment and high rates of comorbidity. Moreover, recent research suggests that chronic depression may affect women more seriously than men; for example, women may experience illness onset at an earlier age and experience more severe psychosocial impairment compared with men. Recent studies have demonstrated the efficacy of both antidepressant medications and psychotherapy in treating chronic depression, with differential responsiveness to some treatments between women and men. Young women should be screened carefully and treated vigorously to prevent the serious consequences of this condition.
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