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:: Artigos ::
Psychotic symptom and cannabis relapse
in recent-onset psychosis: Prospective study.
ORYGEN Research Centre, Department of Psychiatry, University
of Melbourne, Locked Bag 10, Parkville, Melbourne, Victoria Australia,
3052.
BACKGROUND: Cannabis use appears to exacerbate psychotic symptoms
and increase risk of psychotic relapse. However, the relative
contribution of cannabis use compared with other risk factors
is unclear. The influence of psychotic symptoms on cannabis use
has received little attention. AIMS: To examine the influence
of cannabis use on psychotic symptom relapse and the influence
of psychotic symptom severity on relapse in cannabis use in the
6 months following hospital admission. METHOD: At baseline, 84
participants with recent-onset psychosis were assessed and 81
were followed up weekly for 6 months, using telephone and face-to-face
interviews. RESULTS: A higher frequency of cannabis use was predictive
of psychotic relapse, after controlling for medication adherence,
other substance use and duration of untreated psychosis. An increase
in psychotic symptoms was predictive of relapse to cannabis use,
and medication adherence reduced cannabis relapse risk. CONCLUSIONS:
The relationship between cannabis use and psychosis may be bidirectional,
highlighting the need for early intervention programmes to target
cannabis use and psychotic symptom severity in this population.
PMID: 16880483 [PubMed - in process]
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Medical Cannabis Is A Blunt Tool
Main Category:
Article Date: 28 Jul 2006 - 0:00am (PDT)
IF anecdotes and ancient medicine are to be trusted, cannabis
is a wonder drug. Yet results of clinical trials have been mixed
and its use in modern medicine remains limited. Now it seems the
reasons may be practical as much as political and cultural: there
are fundamental problems with how our bodies respond to the stuff.
Some compounds in cannabis, including THC and cannabidiol, interfere
with a natural signalling system throughout our brains, nerves
and immune system. This system, which produces its own cannabis-like
compounds called endocannabinoids, plays a role in many medical
conditions including pain, epilepsy, multiple sclerosis, Parkinson's
disease, depression and schizophrenia.
Because the system is so widespread, smoking or ingesting cannabis
is bound to have varied effects, including its influence on the
mind. Now it seems that even with purified cannabis extracts,
changing the amount, time or place of a dose could produce completely
opposite effects on the body, according to evidence presented
at the Federation of European Neuroscience Societies (FENS) meeting
in Vienna earlier this month. This could explain why the medical
benefits have proved so difficult to harness.
In one study, Vincenzo Di Marzo of the National Research Council
in Pozzuoli, Italy, boosted levels of an endocannabinoid called
andandamide in rats engineered to develop an Alzheimer's-like
disease. This appeared to protect the rats from memory loss and
nerve degeneration. But if the rise was prolonged, cannabinoids
became ineffective or even damaging.
Beat Lutz of the University of Mainz in Germany found a similar
paradox in models of epilepsy in mice. Anandamide is synthesised
during epileptic fits, providing a natural calming effect. “If
we apply cannabinoids we should protect from seizures,”
says Lutz. “But no, we actually get worsening of seizures
in mice.”
He believes he has found the reason. The main class of cannabinoid
receptor, called CB1 receptors, occurs in two distinct populations
of neurons, those that excite neighbouring neurons and those that
inhibit them - so cannabinoids can have opposite effects depending
on which neurons they hit. David Baker, a multiple sclerosis expert
at University College London has found the same problem in MS.
Mice that have been engineered to have a condition like MS and
no CB1 receptors suffer much worse nerve damage than those with
normal CB1 receptors, suggesting that cannabinoids are involved
in protecting against the nerve damage seen in MS. But other experiments
in mice have shown that cannabinoid signalling also prompts release
of stress hormones called glucocorticoids that can kill neurons.
The greatest anecdotal evidence for the medical benefits of cannabis
comes from its painkilling properties, and animal models have
produced promising results. Yet even here new evidence suggests
that an endocannabinoid called NADA binds not only to cannabinoid
receptors but to a completely different class of receptor as well,
where it mimicks the effect of a pain-producing chemical called
capsaicin, says J. Michael Walker of Indiana University in Bloomington,
who also presented his research at FENS. This may explain why
human trials of cannabis for the treatment of pain have produced
mixed results.
“The problem with cannabis is that there's no way of targeting
the drug to any particular place,” says Baker.
The answer will be to manipulate the system from within, he says.
New ways of amplifying natural cannabinoid release include reuptake
inhibitors that prolong this release just as Prozac does for serotonin.
Such methods look promising for a range of conditions from pain
and cancer to nerve degeneration and MS.
Other methods now being tried in the lab include the manipulation
of enzymes that make and deliver endocannabinoids, as well as
compounds that stimulate and block them. Drugs that bind to CB1
receptors and alter their efficiency are also being discovered,
says Roger Pertwee, director of pharmacology at GW Pharmaceuticals,
based in Porton Down Science Park, Wiltshire, UK. His company
developed Sativex, the first pharmaceutical cannabis extract to
gain clinical approval.
Ironically, the first offshoot of endocannabinoid research to
gain clinical approval, last month, has the opposite effect to
cannabis: Acomplia (rimonabant), an appetite suppressant, works
by blocking CB1 receptors (New Scientist, 8 July, p 5).
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Beyond Evidence: The Moral Case for
International Mental Health
Vikram Patel, Ph.D., Benedetto Saraceno, M.D. and Arthur Kleinman,
M.D.
Introduction
The global burden of disease attributable to mental, neurological,
and substance use disorders is expected to rise from 12.3% in
2000 to 14.7% in 2020 (1). This rise will be particularly sharp
in developing countries. Research has documented the socioeconomic
determinants of many disorders, the profound impact on the lives
of those affected and their families, and the lack of appropriate
care in developing countries. The enormous gap between mental
health needs and the services in developing countries has been
documented in international reports, culminating in the World
Health Report 2001 (2). This evidence has increased the profile
of international mental health, but action still remains limited.
With every new public health challenge, mental health is once
more relegated to the background. We argue that moral arguments
are just as important as evidence to make the case for mental
health intervention. At the center of these moral arguments is
the need to reclaim the place of mental health at the heart of
international public health. We consider some moral arguments
for international mental health and an example from another area
of public health in which the moral case was an important enough
argument for making policy changes and implementing interventions.
No health without mental health
Mental health is closely linked with virtually all global public
health priorities. Alcohol abuse is a major risk factor for unsafe
sexual behavior, and persons with human immunodeficiency virus/acquired
immune deficiency syndrome (HIV/AIDS) have high rates of cognitive
impairment and depression (3). Stress and anxiety predispose to
myocardial infarction, and the latter leads to higher rates of
depression (4). Maternal depression is associated with childhood
failure to thrive in developing countries; failure to thrive can
lead to developmental delays and psychiatric problems in later
life (5). Alcohol abuse and personality disorder frequently precede
violence and depression, and suicide frequently follows (6). The
moral case is that there is no health without mental health. Mental
health interventions must be tied to any program dealing with
physical health.
Mental disorders are treatable in developing countries
Clinical trials have demonstrated the efficacy and cost-effectiveness
of locally feasible treatments for depression, schizophrenia,
and substance abuse in developing countries (7–9). All these
studies share one finding: mental illnesses can be treated with
cheap and technically simple treatments. The work of committed
grassroots organizations demonstrates how this sector has been
implementing mental health interventions at low cost (10). The
moral case is that it is unethical to deny effective, acceptable,
and affordable treatment to millions of persons suffering from
treatable disorders. Community and primary care treatment programs
must be generously supported by donor agencies.
Paying for new psychiatric drugs
Many developing countries were able to produce generic versions
of drugs because of a less rigid enforcement of international
patent regulation. Since a substantial proportion of drug costs
are met out of pocket, this allowed newer medications to be accessible
to low-income groups. This situation was changed with the enforcement
of the Trade Related Intellectual Property Rights international
agreement in 2005. The agreement dictates that any drug patented
after 2005 will not be available except at the price set by the
company that holds the patent (11). Governments can exempt diseases
that are life-threatening or national emergencies from the Trade
Related Intellectual Property Rights charter. Mental illness does
not figure as an exemption category. The moral case is that the
mentally ill have a right to access affordable, evidence-based
treatments. Mental illnesses must be excluded from the Trade Related
Intellectual Property Rights charter.
Reversing the brain drain
The most startling finding of the World Health Organization Atlas
report is the impossibly enormous inequity in the distribution
of mental health manpower in the world (12). A tiny fraction of
this manpower resides in regions of the world where over 90% of
the global population lives. Despite this glaring inequity, the
demand for specialists in richer countries only grows, worsening
the brain-drain of mental health resources from developing countries.
The vast majority of these professionals have been trained in
publically funded medical schools. The moral case is that the
people of poor countries should not be paying for the mental health
care of those living in the richer world. There needs to be an
acknowledgment that institutions in developed countries have an
ethical obligation to facilitate the return of professionals and
to foster long-term partnerships with developing countries to
build mental health capacity.
Violating human rights
There is a history of human rights violations of persons with
mental disorders across the world, but today the most disturbing
examples are found in developing countries. The Asia edition of
the newsmagazine Time from Nov. 24, 2003, detailed contemporary
accounts of the lives of people living in mental hospitals in
Southeast Asia. Patients, typically long-term residents, lose
contact with their families, rarely see a mental health professional,
are treated with old drugs with severe side effects, are offered
few rehabilitative therapies, are kept in crowded wards with no
hint of dignity, and are given unmodified electroconvulsive therapy.
The Erwadi tragedy in India in 2001, where over 20 persons with
mental illness were burned to death when a fire swept the healing
temple where they were chained to their beds, reminds us of human
rights abuses that take place under the guise of traditional medicine.
The stigma of mental illness is so great that the mentally ill
are unable to gain employment, finish schooling, marry, live independently,
or have their care paid for by insurance companies. The moral
case is that the rights of the mentally ill continue to be denied
by many sectors in society. We need to provide technical and financial
support for hospitals to reform, to enable the development of
community care programs, to raise mental health literacy in the
community and among health workers, and to ensure that basic rights
are monitored and enforced.
Social change and mental health
Most developing countries are witnessing social and economic changes
at a pace that is unparalleled in history. Not everyone has benefited
from these changes. Economic change is coupled with migration
from rural to urban areas, disrupting social networks and household
economies. The decrease of trade barriers reducing costs of consumer
items is coupled with cheap imports, leading to unemployment of
small-scale entrepreneurs and farmers. The reduction in state
budgets is being most acutely felt in social spending, where they
are most needed. The rising tide of suicides and premature mortality
in some countries, as vividly seen in the alcohol-related deaths
of men in Eastern Europe and the suicides of farmers in India,
indigenous peoples in South America, and young women in rural
areas in China, can be at least in part linked to rapid economic
and social change (13, 14). The moral case is that mental health
problems are not a luxury item on the health agenda of the poor
and marginalized. Mental disorders must be included in programs
directed to promoting the health of the poor and mental health
indicators used to evaluate the larger social impact of globalization.
The overwhelming majority of the 400 million persons with mental
disorders globally are not being provided with even the basic
mental health care that we know they should and can receive. Research
evidence will not reduce this inequity. To make a change, the
moral case must be heard.
Consider the moral argument that persons with HIV/AIDS in developing
countries had the right to access antiretroviral drugs, that the
state had to provide them for free, that drug companies had to
reduce their prices, that apparently complex treatment regimens
could be provided by primary health care providers with appropriate
training and support, that discrimination against people with
HIV/AIDS had to be combated vigorously, and that knowledge about
HIV/AIDS was the most powerful tool to combat stigma. These arguments
were moral and human rights based. The arguments were made by
a coalition of academics, community leaders, people living with
HIV/AIDS, rock stars, and public heroes. The case they made was
so compelling that governments from India to South Africa changed
their policy on antiretroviral drugs. Drug companies agreed to
reduce prices of medicines. The World Health Organization decided
on 35 as their lead initiative, aiming to get antiretroviral drugs
to 3 million people by 2005.
We believe that the time is ripe for such a global mental health
advocacy initiative that makes the moral case for the mentally
ill. It is unacceptable to continue business as usual. Borrowing
from the lessons of our colleagues in other areas of public health,
such an initiative could take the form of a Global Alliance for
Mental Health, under the umbrella of the World Health Organization,
in which mental health professionals work alongside patients,
families, and public health groups. The practical design of policies,
programs, and interventions is most likely to be effective when
articulated with a moral orientation toward sufferers of mental
illnesses. The Alliance’s primary goal would be to spearhead
a movement to increase access to evidence-based care, perhaps
a 510 program to get 5 million untreated patients into treatment
and rehabilitation programs by 2010. Equally important goals would
be to combat stigma through concerted campaigns directed at various
sectors of society and to strengthen the capacity of health systems
to care for the mentally ill. A key task would be to mobilize
the massive resources needed to support mental health program
development in poor countries.
Mental health professionals in rich countries have an important
role to play. They can be advocates to their own health systems
to ensure that the moral case is heard and appropriate actions
supported. As individuals, they can commit their time to activities
that tackle some of the issues on the international mental health
agenda. We believe that our ultimate professional goal as mental
health professionals in a globalized world is to secure a reasonable
opportunity for people with mental disorders to achieve better
health outcomes. We already have the evidence we need to make
the case for international mental health; it is the moral argument
that we now need to make.
Footnotes
Address correspondence and reprint requests to Dr. Patel, Sangath
Centre, Alto-Porvorim, Goa India 403521; vikram.patel{at}lshtm.ac.uk
(e-mail). Drs. Patel, Saraceno, and Kleinman report no conflict
of interest.
References
Murray CJL, Lopez AD: Alternative projections of mortality
and disability by cause 1990-2020: global burden of disease study.
Lancet 1997; 349:1498–1504
World Health Organization: The World Health Report 2001: Mental
Health: New Understanding, New Hope. Geneva, WHO, 2001
Catalan J (ed): Mental Health and HIV Infection. Psychological
and Psychiatric Aspects. London, Taylor & Francis, 1999
Penninx BWJH, Beekman AT, Honig A, Deeg DJH, Schoevers RA, van
Eijk JTM, van Tilburg W: Depression and cardiac mortality: results
from a community-based longitudinal study. Arch Gen Psychiatry
2001; 58:227
Patel V, Rahman A, Jacob KS, Hughes M: Effect of maternal mental
health on infant growth in low income countries: new evidence
from South Asia. BMJ 2004; 328:820–823
World Health Organization: World Report on Violence and Health:
Summary. Geneva, WHO, 2002
Chatterjee S, Patel V, Chatterjee A, Weiss H: Evaluation of a
community based rehabilitation model for chronic schizophrenia
in a rural region of India. Br J Psychiatry 2003; 182:57–62
Patel V, Araya R, Bolton P: Treating depression in developing
countries. Trop Med Int Health 2004; 9:539–541
Wu Z, Detels R, Zhang J, Li V, Li J: Community-based trial to
prevent drug use amongst youth in Yunnan, China. Am J Public Health
2002; 92:1952–1957
Patel V, Thara R: Meeting Mental Health Needs in Developing Countries:
NGO Innovations in India. New Delhi, Sage Publications, 2003
Patel V, Andrade C: Pharmacological treatment of severe psychiatric
disorders in the developing world: lessons from India. CNS Drugs
2003; 17:1071–1080
World Health Organization: Atlas Country Profiles of Mental Health
Resources. Geneva, WHO, 2001
Sundar M: Suicide in farmers in India. Br J Psychiatry 1999; 175:585–586
Phillips MR, Liu H, Zhang Y: Suicide and social change in China.
Cult Med Psychiatry 1999; 23:25–50
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Europe's mental health
strategy
Responsibility extends beyond health authorities
Many countries in western Europe are experiencing increasing
numbers of sickness spells and early retirements due to mental
disorders and problems.1 However, the importance of good mental
health is still not acknowledged universally. In the era of the
information society, mental stressors are public health threats
of increasing magnitude.
A recently presented green paper by the European Commission on
mental health promotes discussion on the relation between the
European Union's strategic policy objectives and the mental health
of Europeans.2 The paper builds on the Helsinki Action Plan of
the World Health Organization's European Ministerial Conference
on Mental Health 2005.3 The potential adoption of a union-wide
mental health strategy later this year could signal an upgrade
in the status of mental health issues within the union and within
each member state.
The paper acknowledges the need for European action on mental
health. Each year, about 60 000 European Union citizens die from
suicide, more than the total annual deaths from road traffic accidents.4
Meanwhile, many countries still have no suicide prevention policy,5
even though evidence based measures for suicide prevention are
effective and available.6 The economic consequences of mental
health problems—mainly in the form of lost productivity—are
estimated to be 3-4% of gross national product.7 In any given
year a quarter of Europeans are likely to be affected by mental
disorders,8 while only 25% of these will have contact with formal
health services.9
The new mental health strategy proposed by the green paper should
focus on the promotion of mental health, preventive actions, social
inclusion, and the protection of the rights of people with mental
disorders, as well as on developing a European mental health information
system. The lessons of the successful control of infectious and
cardiovascular diseases indicate that the road to improved mental
health among populations lies not in investment in mental health
services but in promotion and prevention activities. Yet these
remain challenging, as individual, familial, and societal determinants
of mental health often lie in non-health domains such as social
policy, education, and urban planning. Promising new evidence
has, however, indicated that effective interventions exist10:
interventions in local communities,11 home visiting programmes,12
and school programmes13 are some examples of effective interventions
for improving mental health.
Mental health is a marginal issue in existing European Union health
infrastructures, and there is no specific unit devoted to mental
health either in the European Commission services or at the European
Centre for Disease Control. Though the need for a mental health
information system is acknowledged in the paper, it does not suggest
any sustainable European infrastructures for monitoring and information
dissemination. There is an obvious need for new European institutions
to complement and support national activities; such structures
could include a European clearinghouse for evidence on mental
health interventions, an institute providing guidelines on mental
health practice, and an observatory for mental health. None of
these activities exist today on a sustainable basis in spite of
the achievable European benefits that would be gained.
The European Commission has been given the chance to take a lead
and contribute to the introduction of progressive national and
regional mental health policies in Europe. Many countries have
neglected the need for a comprehensive mental health policy for
too long.5 For the most part, mental health is seen as a matter
for health authorities only, and many existing policies focus
on the development of services. The commission can change this
pattern by advocating the inclusion of mental health not only
in European public health policy but also in social and employment
policy; research policy; and freedom, justice, and security policies.
Such a shift would likewise transform the alcohol policy of the
European Union, in which mental health considerations have so
far been notoriously overshadowed by trade considerations.
The commission's green paper is open for consultation by member
states, organisations, and individual citizens (http://europa.eu.int/comm/health/ph_determinants/life_style/mental
/green_paper/consultation_en.htm).
Input into the consultation will help shape the future mental
health of Europeans. The European Parliament's response to the
green paper is scheduled for September and is an opportunity to
raise awareness and political commitment for mental health issues.
Mental health is a major challenge for European health policy.
Good mental health contributes to prosperity, solidarity, and
social justice, and cannot be achieved by the health sector alone.
All sectors have to be involved in the promotion of mental health.
Kristian Wahlbeck, professor
STAKES National Research and Development Centre of Welfare and
Health, PO Box 220, Helsinki 00531, Finland
(kristian.wahlbeck{at}stakes.fi )
Vappu Taipale, director general
STAKES National Research and Development Centre of Welfare and
Health, PO Box 220, Helsinki 00531, Finland
Competing interests: None declared.
References
Järvisalo J, Andersson B, Boedeker W, Houtman I, eds. Mental
disorder as a major challenge in prevention of work disability.
Social security and health reports 66. Helsinki: Social Insurance
Institution, 2005.
European Commission, Health & Consumer Protection Directorate-General.
Green paper. Improving the mental health of the population: towards
a strategy on mental health for the European Union. Luxembourg:
EC, 2005. (http://europa.eu.int/comm/health/ph_determinants/life_style
/mental/green_paper/mental_gp_en.pdf.)
WHO Regional Office for Europe. Mental health: facing the challenges,
building solutions. Copenhagen: WHO Regional Office for Europe,
2005. (www.who.dk/document/E87301.pdf.)
WHO Regional Office for Europe. European health for all database
(HFA-DB). www.euro.who.int/hfadb
(accessed 24 Feb 2006).
European Commission, Health & Consumer Protection Directorate-General.
Mental health promotion and mental disorder prevention across
European member states: a collection of country stories. 2nd ed.
Luxembourg: EC, 2006. (www.imhpa.net/fileadmin/imhpa/Country_stories/FINAL.pdf.)
Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A,
et al. Suicide prevention strategies. A systematic review. JAMA
2005;294: 2064-74.
Gabriel P, Liimatainen M-R. Mental health in the workplace. Geneva:
International Labour Office, 2000.
Wittchen H-U, Jacobi F. Size and burden of mental disorders in
Europe—a critical review and appraisal of 27 studies. Eur
Neuropsychopharmacol 2005;15: 357-76.
Alonso J, Angermeyer C, Bernert S, Bruffaerts R, Brugha TS, Bryson
H, et al for the ESEMeD/MHEDEA 2000 Investigators Scientific Committee.
Use of mental health services in Europe: Results from the European
study of the epidemiology of mental disorders (ESEMeD) project.
Acta Psychiatr Scand Suppl 2004;(420): 47-54.
Doughty C. The effectiveness of mental health promotion, prevention
and early intervention in children, adolescents and adults. A
critical appraisal of the literature. NZHTA Report 2005;8(2).
Hawkins D, Catalano R, Arthur M. Promoting science-based prevention
in communities. Addict Behav 2002;27: 951-76.
Olds DL. Prenatal and infancy home visiting by nurses: from randomized
trials to community replication. Prev Sci 2002;3: 1153-72.
Patton GC, Glover S, Bond L, Butler H, Godfrey C, Di Pietro G,
et al. The Gatehouse project: a systematic approach to mental
health promotion in secondary schools. Aust N Z J Psychiatry 2000;34:
586-93.
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Terapia cognitivo-comportamental para
síndrome da fadiga crônica: estudo multicêntrico,
randomizado e controlado
Cognitive behaviour therapy for chronic fatigue syndrome: a multicentre
randomised controlled trial
Judith B Prins, Gijs Bleijenberg, Ellen Bazelmans, Lammy D Elving,
Theo M de Boo, Johan L Severens, Gert Jan van der Wilt, Philip
Spinhoven, Jos W M van der Meer
Histórico: terapia cognitivo-comportamental (TCC) parece
ser um tratamento promissor para síndrome da fadiga crônica
(SFC), mas a aplicabilidade desse tratamento fora de serviços
especializados é questionada. Nós comparamos TCC,
grupos de suporte e evolução natural em um estudo
randomizado em três centros.
Métodos: de 476 pacientes com diagnóstico de SFC,
278 eram elegíveis e concordaram em participar. Noventa
e três foram designados para TCC (ministrada por 13 terapeutas
recentemente treinados para essa técnica), 94 foram designados
para grupos de suporte e 91 tiveram evolução natural
da doença. Avaliações multidimensionais foram
realizadas na linha basal, em 8 meses e em 14 meses. O desfecho
primário foi gravidade da fadiga (em uma lista individual
para avaliação de força) e disfunção
(perfil de impacto da doença) em 8 e 14 meses. Os dados
foram analisados por intenção de tratamento.
Resultados: 241 pacientes tiveram dados completos (83 TCC, 80
grupo de suporte, 78 evolução natural). Em 14 meses,
TCC foi significativamente mais efetiva do que ambos os grupos
controles para gravidade de fadiga (TCC vs suporte 5,8 [2,2-9,4];
TCC vs evolução natural 5,6 [2,1-9,0]) e para disfunção
(TCC vs suporte 263 [38-488]; TCC vs evolução natural
222 [3-441]). Grupos de suporte não foram mais efetivos
para pacientes com SFC do que evolução natural.
Entre o grupo TCC, melhora clinica significante foi observada
na gravidade da fadiga em 20 de 58 (35%) pacientes, em Karnofsky
performance status para 28 de 57 (49%), e em melhora auto-referida
para 29 de 58 (50%). Fatores prognósticos para desfechos
após TCC foram um mais alto senso de controle como preditor
de maior melhora e um padrão passivo de atividade e foco
em sintomas corporais como preditores de pior melhora.
Conclusão: TCC foi mais efetiva do que grupos de suporte
e que evolução natural em um estudo multicêntrico
com vários terapeutas. Nosso estudo demonstra uma proporção
mais baixa de pacientes com melhora do que em estudos de TCC com
um menor número de terapeutas, porém mais hábeis.
Fonte: Lancet 2001; 357: 841-47
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